Comparative effects of celiprolol, propranolol, oxprenolol, and atenolol on respiratory function in hypertensive patients with chronic obstructive lung disease

Under-utilisation of β-blockers in patients with acute coronary syndrome and comorbid chronic obstructive pulmonary disease

BACKGROUND

β-blockers are an established mainstay of therapy in acute coronary syndrome (ACS). Despite substantial evidence of their safety and efficacy in chronic obstructive pulmonary disease (COPD) patients, their use in this population remains limited internationally, likely due to fears of inducing bronchospasm. In Australia, little is known about the use of β-blockers in COPD patients hospitalised for ACS.

AIM

To determine if β-blockers are under-prescribed at discharge for patients with COPD hospitalised for ACS compared to patients without a diagnosis of COPD.

METHODS

Retrospective analysis of a tertiary metropolitan hospital computer database was undertaken to identify the first 250 patients hospitalised with ACS from 1 March 2015.

RESULTS

Of the 250 patients analysed, there were five in-hospital fatalities, leaving 245 patients for final analysis. Patients with ACS and COPD received fewer β-blockers at discharge than those with ACS alone (66.7% vs 86.2%, P < 0.05). After controlling for clinically meaningful confounding factors, a logistic regression analysis model determined that, for patients with ACS, the presence of COPD was the only significant predictor of receiving a β-blocker at discharge.

CONCLUSION

Despite strong evidence supporting the use of β-blockers in COPD patients with ACS, Australian patients with COPD remain under-treated for ACS. More work is needed to alter prescribing attitudes.

Metoprolol prevents chronic obstructive sleep apnea-induced atrial fibrillation by inhibiting structural, sympathetic nervous and metabolic remodeling of the atria

Chronic obstructive sleep apnea (OSA) may promote the development of atrial fibrillation (AF) by inducing atrial electrical and structural remodeling as well as autonomic nerve hyperinnervation. Here, we investigated the roles of metoprolol in regulation of atrial remodeling induced by chronic OSA. A canine model of chronic OSA was established by stopping the ventilator and closing the airway for 4 h/day every other day for 12 weeks, while metoprolol (5 mg·kg-1·day-1) was continuously administered. Using that model, we observed that increases in sympathetic sprouting and atrial structural remodeling were sharply inhibited by metoprolol. Moreover, metoprolol dramatically inhibited the impairment of atrial energy metabolism by activating the Sirt1-AMPK pathway. In vitro, metoprolol significantly activated the Sirt1-AMPK pathway in intermittent hypoxic and isoproterenol-treated HL-1 cells, and the effect was abolished by the coadministration of EX-527, an inhibitor of Sirt1 activation. In summary, metoprolol protects against chronic OSA-induced atrial remodeling. Our results suggest a new and feasible treatment strategy for AF induced by OSA.

Celiprolol: A Unique Selective Adrenoceptor Modulator

Celiprolol is a β-blocker with a unique pharmacologic profile: it is a β1-andrenoceptor antagonist with partial β2 agonist activity. Given this combination of effects, celiprolol may be better described as a selective adrenoreceptor modulator. It has antihypertensive and antianginal properties and is indicated for those uses in various countries around the world. In the United States, however, the proposed indication for this drug will be for the treatment of vascular type Ehlers–Danlos syndrome, a rare connective tissue disorder characterized by fragile arterial structure and an increased risk of life-threatening vascular complications. By reducing heart rate and pulsatile pressure, celiprolol may reduce the mechanical stress on collagen fibers within the arterial wall and be of benefit in patients with vascular type Ehlers–Danlos syndrome. The largest investigation of celiprolol in vascular Ehlers–Danlos syndrome was prematurely terminated due to significant benefit with celiprolol in reducing arterial events in patients with this condition. Celiprolol, therefore, represents a β-blocker that is unique from others in its class in both its pharmacology and clinical applications.

Paradigms in chronic obstructive pulmonary disease: phenotypes, immunobiology, and therapy with a focus on vascular disease

Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous syndrome that represents a major global health burden. COPD phenotypes have recently emerged based on large cohort studies addressing the need to better characterize the syndrome. Though comprehensive phenotyping is still at an early stage, factors such as ethnicity and radiographic, serum, and exhaled breath biomarkers have shown promise. COPD is also an immunological disease where innate and adaptive immune responses to the environment and tobacco smoke are altered. The frequent overlap between COPD and other systemic diseases, such as cardiovascular disease, has influenced COPD therapy, and treatments for both conditions may lead to improved patient outcomes. Here, we discuss current paradigms that center on improving the definition of COPD, understanding the immunological overlap between COPD and vascular inflammation, and the treatment of COPD-with a focus on comorbid cardiovascular disease.

β-Blockers for the prevention of acute exacerbations of chronic obstructive pulmonary disease (βLOCK COPD): a randomised controlled study protocol

INTRODUCTION

A substantial majority of chronic obstructive pulmonary disease (COPD)-related morbidity, mortality and healthcare costs are due to acute exacerbations, but existing medications have only a modest effect on reducing their frequency, even when used in combination. Observational studies suggest β-blockers may reduce the risk of COPD exacerbations; thus, we will conduct a randomised, placebo-controlled trial to definitively assess the impact of metoprolol succinate on the rate of COPD exacerbations.

METHODS AND ANALYSES

This is a multicentre, placebo-controlled, double-blind, prospective randomised trial that will enrol 1028 patients with at least moderately severe COPD over a 3-year period. Participants with at least moderate COPD will be randomised in a 1:1 fashion to receive metoprolol or placebo; the cohort will be enriched for patients at high risk for exacerbations. Patients will be screened and then randomised over a 2-week period and will then undergo a dose titration period for the following 6 weeks. Thereafter, patients will be followed for 42 additional weeks on their target dose of metoprolol or placebo followed by a 4-week washout period. The primary end point is time to first occurrence of an acute exacerbation during the treatment period. Secondary end points include rates and severity of COPD exacerbations; rate of major cardiovascular events; all-cause mortality; lung function (forced expiratory volume in 1 s (FEV1)); dyspnoea; quality of life; exercise capacity; markers of cardiac stretch (pro-NT brain natriuretic peptide) and systemic inflammation (high-sensitivity C reactive protein and fibrinogen). Analyses will be performed on an intent-to-treat basis.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Department of Defense Human Protection Research Office and will be approved by the institutional review board of all participating centres. Study findings will be disseminated through presentations at national and international conferences and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02587351; Pre-results.

The safety and tolerability of beta blockers in heart failure with reduced ejection fraction: is the current underutilization of this evidence-based therapy justified?

INTRODUCTION

Beta blockers are one of the cornerstones for treatment of Heart Failure with Reduced Ejection fraction (HFRef), yet their use is often limited by adverse effects, either perceived or real. We performed a review of available data using PubMed.gov utilizing beta blocker, heart failure, reduced ejection fraction and safety as key words.

AREAS COVERED

Several well designed, large scale randomized clinical trials including CIBS-II (bisoprolol), MERIT-HF (metoprolol succinate), and Copernicus (carvedilol) among others, have been conducted in patients with HFRef and demonstrated an improvement in cardiac mortality and morbidity. Despite the preponderance of data supporting the use of beta blockers for patients HFRef, these medications remain underutilized and/or are often prescribed at lower than recommended dosages. Some of the reluctance to embrace beta blockade may be attributed to concern on the part of both the patient and prescriber about the non-cardiac adverse effects of this class of drugs. We have reviewed several recent reviews and meta-analyses of trials of beta blocker in heart failure which have conclusively demonstrated their tolerability in the populations studied.

EXPERT OPINION

In the final section of this paper we provide our opinions regarding initiating and optimizing beta blocker therapy for patients with HFRef.

Adverse respiratory effect of acute β-blocker exposure in asthma: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

β-Blockers are avoided in asthma over concerns regarding acute bronchoconstriction. Risk is greatest following acute exposure, including the potential for antagonism of β2-agonist rescue therapy.

METHODS

A systematic review of databases was performed to identify all randomized, blinded, placebo-controlled clinical trials evaluating acute β-blocker exposure in asthma. Effect estimates for changes in respiratory function, symptoms, and β2-agonist response were pooled using random effects meta-analysis with heterogeneity investigated.

RESULTS

Acute selective β-blockers in the doses given caused a mean change in FEV1 of −6.9% (95% CI, −8.5 to −5.2), a fall in FEV1 of ≥20% in one in eight patients (P=.03), symptoms affecting one in 33 patients (P=.18), and attenuation of concomitant β2-agonist response of −10.2% (95% CI, −14.0 to −6.4). Corresponding values for acute nonselective β-blockers in the doses given were −10.2% (95% CI, −14.7 to −5.6), one in nine patients (P=.02), one in 13 patients (P=.14), and −20.0% (95% CI, −29.4 to −10.7). Following investigation of heterogeneity, clear differences were found for celiprolol and labetalol. A dose-response relationship was demonstrated for selective β-blockers.

CONCLUSIONS

Selective β-blockers are better tolerated but not completely risk-free. Risk from acute exposure may be mitigated using the smallest dose possible and β-blockers with greater β1-selectivity. β-Blocker-induced bronchospasm responded partially to β2-agonists in the doses given with response blunted more by nonselective β-blockers than selective β-blockers. Use of β-blockers in asthma could possibly be based upon a risk assessment on an individual patient basis.

Treatment of infantile haemangiomas with atenolol: comparison with a historical propranolol group

Propranolol, a lipophilic non-selective beta-blocker, has proven to be effective in the treatment of infantile haemangioma (IH). However, several side effects have been reported. Atenolol, a hydrophilic selective beta-1 blocker, could be an alternative and associated with fewer side effects. Thirty consecutive patients with IH were treated with atenolol between June 2010 and May 2011. The therapeutic effect was judged by clinical assessment and quantified by using a visual analogue scale (VAS) and the Haemangioma Activity Score (HAS). Side effects were also evaluated. The atenolol cohort was compared with a previously described cohort of 28 patients treated with propranolol between July 2008 and December 2009. Clinical involution was present in 90% (27/30) of the IH patients treated with atenolol. Mild side effects occurred in 40% (12/30) of these patients and severe side effects occurred in 3% (1/30). Compared with the previously described cohort treated with propranolol, mild side effects occurred in 50% (14/28) and severe side effects in 25% (7/28) of the patients (p=0.04). Quantitative improvement of the IH in the atenolol group (n=27) showed no significant difference in either the VAS score or the HAS compared to the propranolol group (n=24). This study indicates that atenolol is effective in the treatment of IH. Compared with a historical control group treated with propranolol, the effects of atenolol seem to be similar and less frequently associated with severe side effects. Randomised clinical trials are necessary to evaluate the efficacy and safety of atenolol treatment in IH.

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.

Cardioselective beta-blocker treatment of hypertension in patients with asthma: when do benefits outweigh risks?

BACKGROUND

Benefits outweigh risks of cardioselective beta-blocker therapy in patients with nonsevere asthma and a history of heart failure or myocardial infarction (MI). This review summarizes the risks versus benefits of using cardioselective beta-blockers in the treatment of hypertension in patients with asthma.

METHODS

We searched the English literature from 1976 to 2011 via PubMed, EMBASE, and SCOPUS using the following search terms: "beta-blocker treatment of hypertension" AND "asthma"; "cardioselective beta-blockers" AND "asthma." When pertinent articles were found, we assessed relevant articles cited in those papers. All studies related to cardioselective beta-blocker use in patients with asthma and hypertension were included.

RESULTS

Seven studies with patient populations ranging from 10 to 17 patients evaluated cardioselective beta-blockers in patients with asthma and hypertension. Atenolol and/or immediate-release metoprolol were evaluated in these studies. The duration of beta-blocker therapy in four studies was 1-8 weeks; two studies were single dose and one investigation lasted 8 months. Metoprolol and atenolol were generally well tolerated except at higher doses such as metoprolol >100 mg daily.

CONCLUSION

In the absence of concomitant cardiovascular disease, routine use of beta-blockers for the treatment of hypertension in patients with asthma should be avoided.

Beta-blocker therapy in patients with left ventricular systolic dysfunction and chronic obstructive lung disease in an ambulatory care setting

Objective:

To evaluate beta blocker persistence six months after beta-blocker initiation or dose titration in heart failure (HF) patients with COPD compared to those without COPD. Secondary objectives included comparison of beta-blocker dose achieved, changes in left ventricular ejection fraction (LVEF) and incidence of hospitalizations or emergency department (ED) visits during follow-up.

Methods:

We conducted a matched, retrospective, cohort study including 86 patients with COPD plus concomitant HF (LVEF ≤40%) and 137 patients with HF alone. All patients were followed in an outpatient HF clinic. Eligible patients had a documented LVEF ≤40% and were initiated or titrated on a beta-blocker in the HF clinic. Patients were matched based on LVEF (categorized as ≤ 20% or 21-40%), gender, and age (> or ≤70 years). The primary outcome was beta blocker persistence at 6 months. Secondary outcomes were dose achieved, LVEF, and incidence of hospitalizations or ED visits.

Results:

There were no differences between the COPD and non-COPD groups in beta-blocker persistence at six-month follow-up (94.2% vs. 93.4% respectively, adjusted p=0.842). The proportion of patients who achieved a daily metoprolol dose equivalent of at least 100 mg was similar between the groups (adjusted p=0.188). The percent of patients with at least one ED visit or hospitalization in the six-month post-titration period was substantial but similar between the groups (53.5% and 48.2% for COPD and non-COPD patients, respectively, adjusted p=0.169).

Conclusion:

Our results support the use of beta-blockers in the population of heart failure patients with COPD and without reactive airway disease.

Are tolerability concerns a class effect of beta-blockers in treating patients with hypertension?

Beta-blockers (beta-blockers) have demonstrated their value across the cardiovascular disease spectrum. Beta-blockers effectively lower blood pressure in patients with hypertension and provide symptomatic or mortality benefits in patients with heart failure and in post-myocardial infarction patients. However, despite their utility, beta-blockers remain underused. There have been recent concerns that beta-blockers as a class are not as effective as once thought in uncomplicated hypertension due to a relatively weak effect on reduction of stroke and the absence of an effect on coronary heart disease when compared with placebo or no treatment. Underuse can, in part, be related to tolerability concerns. Beta-blockers have been traditionally associated with side effects including depression, fatigue, sexual dysfunction, and cold extremities, which limit their acceptance by patients and physicians and may lead to discontinuation of therapy. Because of inherent heterogeneity of the beta-blocker class in terms of adrenergic receptor selectivity, intrinsic sympathomimetic activity, and vasodilatory activity, these agents vary in tolerability profile. Recently, more attention has been focused on the third-generation vasodilatory beta-blockers (ie, carvedilol, labetalol, and nebivolol), with the recognition that these agents may diverge in meaningful ways from the traditional beta-blockers. By examining the differences among members of the beta-blocker class, it may be possible to determine whether and which tolerability issues are indeed a class effect of beta-blockers or whether these agents should be evaluated on a case-by-case basis.

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.

Effect of a community heart failure clinic on uptake of beta blockers by patients with obstructive airways disease and heart failure

OBJECTIVE

To determine the pattern of beta blocker prescribing over one year in a heart failure clinic with a structured approach towards initiation and dose titration and to give a real life perspective on beta blocker use, compliance, and target dose achievement.

METHODS

Data were retrospectively analysed on 513 consecutive patients regularly attending a community heart failure clinic over a year. Systolic dysfunction was determined from two dimensional echocardiography (left ventricular ejection fraction < or = 40%) and lung function was assessed by spirometry. All patients were considered for beta blocker initiation and dose up titration.

RESULTS

Within one year 157 patients died. 143 patients started beta blockers resulting in 315 (88%) patients taking beta blockers at one year; 38% were taking the target dose. 124 had evidence of airways obstruction at baseline, 100 (81%) of whom were taking beta blockers at one year. Forced expiratory volume in one second (1.1 v 1.5 l, p < 0.01) and forced vital capacity (2.3 v 2.5 l/min, p = 0.2) were not reduced in patients with airways obstruction who received beta blockers. Daily doses of beta blockers at one year did not differ statistically between patients with obstructive and patients with non-obstructive spirometry results. 12 patients discontinued beta blockers and 14 required dose reduction due to side effects.

CONCLUSION

The majority of patients with heart failure and obstructive airways disease can safely tolerate low dose initiation and gradual up titration of beta blockers.

Therapeutic Update: Non-Selective Beta- and Alpha-Adrenergic Blockade in Patients With Coexistent Chronic Obstructive Pulmonary Disease and Chronic Heart Failure

Patients with chronic heart failure (CHF) have a resting restrictive ventilatory defect. Any type of exercise requires patients with CHF to markedly increase their minute ventilation. Patients with chronic obstructive pulmonary disease (COPD) have airflow obstruction that leads to dynamic lung hyperinflation and reduced ventilatory response to exercise. Because exercise is associated with abnormally high minute ventilation in patients with CHF and with a limited minute ventilation increase in patients with COPD, functional capacity is severely impaired in patients with coexistent CHF and COPD. Optimal treatment of both conditions is a prerequisite to maximally improve functional capacity in patients with CHF and COPD. Unfortunately, beta-adrenergic blockade, the current cornerstone of CHF therapy, is frequently omitted in patients with CHF and COPD for fear of inducing bronchoconstriction. Furthermore, when prescribed, beta-adrenergic blockade is often attempted with a moderate dose of metoprolol tartrate, a beta-1-blocker that results in lesser clinical benefits than combined non-selective beta-blockade with carvedilol at the maximally recommended dose. Recent experience indicates that combined non-selective beta- and alpha-blockade with carvedilol is well tolerated in patients with COPD who do not have reversible airway obstruction. Alpha-adrenergic blockade may promote mild bronchodilation that offsets non-selective beta blockade-induced bronchoconstriction in patients with obstructive airway disease.

Cardioselective beta-blockers for chronic obstructive pulmonary disease: a meta-analysis

Beta-blocker therapy has a 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). The objective of this study was to assess the effect of cardioselective beta-blockers on respiratory function of patients with COPD. Comprehensive searches were performed of the EMBASE, MEDLINE and CINAHL databases from 1966 to May 2001, and identified articles and related reviews were scanned. Randomised, blinded, controlled trials that studied the effects of cardioselective beta-blockers on the forced expiratory volume in 1 s (FEV1) or symptoms in patients with COPD were included in the analysis. 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. Outcomes measured were the change in FEV1 from baseline and the number of patients with respiratory symptoms. Eleven studies of single-dose treatment and 8 of continued treatment were included. Cardioselective beta-blockers produced no significant change in FEV1 or respiratory symptoms compared to placebo, given as a single dose (-2.05% [95% CI, -6.05% to 1.96%]) or for longer duration (-2.55% [CI, -5.94% to 0.84]), and did not significantly affect the FEV1 treatment response to beta2-agonists. Subgroup analyses revealed no significant change in results for those participants with severe chronic airways obstruction or for those with a reversible obstructive component. In conclusion, cardioselective beta-blockers given to patients with COPD do not produce a significant reduction in airway function or increase the incidence of COPD exacerbations. Given their demonstrated benefit in conditions such as heart failure, coronary artery disease and hypertension, cardioselective beta-blockers should be considered for patients with COPD.

Treatment of systemic hypertension in patients with pulmonary disease: COPD and asthma

We present a two-part review of the English-language literature pertaining to drug therapy for systemic high BP in patients with pulmonary diseases. Part I examines the literature pertaining to the use of antihypertensive drugs in patients with systemic hypertension and coexisting pulmonary conditions, especially COPD and asthma. Part II of the series reviews studies assessing the relationship between sleep-disordered breathing (including the role of the sympathetic nervous system) and systemic hypertension, and presents an approach to the management of these patients. It is the aim of both parts of this review to make qualified conclusions and recommendations applying a methodologic critique to assess the current literature. In the first part of this series, we review the demographics of hypertension in patients with COPD. This is followed by an extensive review of the use of specific classes of antihypertensive drug therapies in patients with pulmonary disease. The antihypertensive agents reviewed include diuretics, calcium antagonists, angiotensin-converting enzyme inhibitors, and angiotensin II receptor antagonists, beta-adrenergic blocking agents, and alpha-beta-blockers and other non-beta-blocker classes. Additionally, the renin angiotensin system is briefly reviewed, with a discussion of how angiotensin-converting enzyme inhibitors induce cough, especially in pulmonary and congestive heart failure patients.

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 EMBASE, MEDLINE and CINAHL was performed using the Cochrane Airways Group registry to identify randomised blinded controlled trials from 1966 to May 2001. The search was completed using the terms: asthma*, bronchial hyperreactivity*, respiratory sounds*, wheez*, obstructive lung disease* or obstructive airway disease*, and adrenergic antagonist*, sympatholytic* or adrenergic receptor block*. 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 8 of treatment for longer duration, ranging from 2 days to 12 weeks, met selection criteria. Cardioselective beta-blockers produced no statistically significant change in FEV1 or respiratory symptoms compared to placebo, given as a single dose (Weighted Mean Difference -2.05% [95% Confidence interval, -6.05 to 1.96%]) or for longer duration (WMD -2.55% [95% CI, -5.94 to 0.84]), and did not significantly affect the FEV1 treatment response to beta2-agonists. Exacerbations and hospitalizations were recorded in all trials, but none occurred during the periods of study, in either group. A subgroup analysis revealed no significant change in results for those participants with severe chronic airways obstruction or for those with a reversible obstructive component.

REVIEWER'S CONCLUSIONS

The available evidence suggests that cardioselective beta-blockers, given to patients with COPD do not produce a significant short-term reduction in airway function or in the incidence of COPD exacerbations. However, the trials were small and of short duration. Given their demonstrated benefit in conditions such as heart failure, coronary artery disease and hypertension, cardioselective beta-blockers should be considered for patients with COPD, but administered with careful monitoring since data concerning long term administration and their effects during exacerbations are not available.

Effect of timolol 0.5% gel and solution on pulmonary function in older glaucoma patients

PURPOSE

To evaluate the effect of timolol maleate solution or gel forming solution versus placebo on pulmonary function in patients with primary open-angle glaucoma or ocular hypertension without reactive airway disease.

METHODS

After a screening visit, each patient was randomized by a Latin square technique to receive placebo twice daily, 0.5% timolol solution twice daily, or 0.5% timolol gel once a day (placebo given as second dose) to each eye for 2 weeks. Subjects then were crossed over to the two other treatments for 2-week treatment intervals. At each visit, patients were received a dose 15 minutes before pulmonary function testing.

RESULTS

This study began with 25 patients, and 20 finished the trial. There was no difference between treatment groups for the forced expiratory volume at one second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio (P > 0.1). The mean FEV1 for timolol solution, timolol gel, and placebo was 2.42 L, 2.45 L, and 2.50 L, respectively. The mean FVC for timolol solution, timolol gel, and placebo was 3.33 L, 3.38 L, and 3.44 L, respectively. No difference in intraocular pressure was observed between the timolol solution (17.1 +/- 3.3 mm Hg) and timolol gel (17.1 +/- 3.6 mm Hg) between the treatment periods (P > 0.1). No difference in side effects was observed between treatment groups (P > 0.05).

CONCLUSIONS

In older patients with primary open-angle glaucoma or ocular hypertension without reactive airway disease, nonselective beta-blockers should not worsen pulmonary function.

Cardioselective beta-blocker use in patients with reversible airway disease

BACKGROUND

Beta-blocker therapy has 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 reversible airway disease.

OBJECTIVES

To assess the effect of cardioselective beta-blockers on respiratory function of patients with reversible airway disease. Reversible airway disease was defined as asthma or chronic obstructive pulmonary disease with a reversible obstructive component.

SEARCH STRATEGY

A comprehensive search of EMBASE, MEDLINE and CINAHL was performed using the Cochrane Airways Group registry to identify randomized blinded placebo-controlled trials from 1966 to February, 2000. The search was completed using the terms: asthma*, bronchial hyperreactivity*, respiratory sounds*, wheez*, obstructive lung disease* or obstructive airway disease*, and adrenergic antagonist*, sympatholytic* or adrenergic receptor block*. We did not exclude trials on the basis of language.

SELECTION CRITERIA

Randomized, blinded, placebo-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), symptoms and use of short-acting inhaled beta-agonists, in patients with reversible airway disease. Reversible airway disease was documented by response to methacholine challenge, by an increase in FEV1 of at least 15% to beta-agonist administration, or the presence of asthma as defined by the American Thoracic Society.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted data from the selected articles, reconciling differences by consensus. Cardioselective beta-blockers were divided into 2 groups, those with or without intrinsic sympathomimetic activity (ISA). Two interventions studied were the administration of beta-blocker, given either as a single dose or for longer duration, and the use of beta-agonist given after the study drug.

MAIN RESULTS

Nineteen studies for single-dose treatment and 10 for treatment of longer duration met selection criteria. The patients had mild-moderate airways obstruction. For cardioselective beta-blockers taken as a group, administration of a single dose was associated with a 7.98% (CI, 6.19 to 9.77%) reduction in FEV1, but with a 13.16% (CI, 10.76 to 15.56%) increase in beta-agonist response, as compared to placebo. There was no increase in symptoms. After treatment lasting a few days to a few weeks, there was no decrement in FEV1 compared to placebo and no increase in symptoms or inhaler use. Regular use of cardioselective beta-blockers without ISA produced a 13.13% (CI, 5.97 to 20.30) increase in beta-agonist response compared to placebo, a response not seen with beta-blockers containing ISA (-0.60% [CI, -11.7 to +10.5%]).

REVIEWER'S CONCLUSIONS

Cardioselective beta-blockers, given to patients with mild-moderate reversible airway disease, do not produce clinically significant adverse respiratory effects in the short term. It is not possible to comment on their effects in patient with more severe or less reversible disease, or on their effect on the frequency or severity of acute exacerbations. Given their demonstrated benefit in conditions such as heart failure, coronary artery disease and hypertension, cardioselective beta-blockers should not be withheld from patients with mild-moderate reversible airway disease.

Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction

BACKGROUND

Long-term administration of beta-adrenergic blockers to patients after myocardial infarction improves survival. However, physicians are reluctant to administer beta-blockers to many patients, such as older patients and those with chronic pulmonary disease, left ventricular dysfunction, or non-Q-wave myocardial infarction.

METHODS

The medical records of 201,752 patients with myocardial infarction were abstracted by the Cooperative Cardiovascular Project, which was sponsored by the Health Care Financing Administration. Using a Cox proportional-hazards model that accounted for multiple factors that might influence survival, we compared mortality among patients treated with beta-blockers with mortality among untreated patients during the two years after myocardial infarction.

RESULTS

A total of 34 percent of the patients received beta-blockers. The percentage was lower among the very elderly, blacks, and patients with the lowest ejection fractions, heart failure, chronic obstructive pulmonary disease, elevated serum creatinine concentrations, or type 1 diabetes mellitus. Nevertheless, mortality was lower in every subgroup of patients treated with beta-blockade than in untreated patients. In patients with myocardial infarction and no other complications, treatment with beta-blockers was associated with a 40 percent reduction in mortality. Mortality was also reduced by 40 percent in patients with non-Q-wave infarction and those with chronic obstructive pulmonary disease. Blacks, patients 80 years old or older, and those with a left ventricular ejection fraction below 20 percent, serum creatinine concentration greater than 1.4 mg per deciliter (124 micromol per liter), or diabetes mellitus had a lower percentage reduction in mortality. Given, however, the higher mortality rates in these subgroups, the absolute reduction in mortality was similar to or greater than that among patients with no specific risk factors.

CONCLUSIONS

After myocardial infarction, patients with conditions that are often considered contraindications to beta-blockade (such as heart failure, pulmonary disease, and older age) and those with nontransmural infarction benefit from beta-blocker therapy.