Association between chronic heart failure and inhaled beta-2-adrenoceptor agonists

Optimal Management of Heart Failure and Chronic Obstructive Pulmonary Disease: Clinical Challenges

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common causes of breathlessness which frequently co-exist; one potentially exacerbating the other. Distinguishing between the two can be challenging due to their similar symptomatology and overlapping risk factors, but a timely and correct diagnosis is potentially lifesaving. Modern treatment for HF can substantially improve symptoms and prognosis for many patients and may have beneficial effects for patients with COPD. Conversely, while many inhaled treatments for COPD can improve symptoms and reduce exacerbations, there is conflicting evidence regarding the safety of some inhaled treatments for COPD in patients with HF. Here we explore the overlap between HF and COPD, examine the effect of one condition on the other, and address the challenges of managing patients with both conditions.

Inhaled Beta2-Agonists Increase In-Hospital Mortality in ICU Patients with Heart Failure

The impact of beta2-agonists (B2As) on heart failure (HF) remains controversial. This study aimed to investigate whether inhaled B2As increased in-hospital mortality in ICU patients with HF.The Multiparameter Intelligent Monitoring in Intensive Care III database was initially searched to identify adult patients (≥ 18 years old) with HF in ICU. Then, patients using or not using inhaled B2As were matched using propensity score matching on a 1:1 basis to control for baseline confounders. In-hospital mortality was compared between the two groups, and logistic regression analysis was performed to assess the association between B2As and in-hospital mortality.The initial search retrieved 2345 eligible patients with HF from the database. After propensity score matching, 705 pairs of patients were included in the final analysis. Patients using B2As had markedly higher in-hospital mortality than those not using B2As (4.68% versus 2.27%; P = 0.013). In the multivariate logistic regression analysis, B2A use (odd ratios (OR), 2.471; 95% confidence interval (CI), 1.289-4.734; P = 0.006), stroke (OR, 4.581; 95% CI, 1.621-12.948; P = 0.004), and simplified acute physiology score II (SAPS-II) scores (OR, 1.090; 95% CI, 1.064-1.116; P < 0.001) were significantly associated with increased risk of in-hospital mortality, whereas renin angiotensin system inhibitor use (OR, 0.396; 95% CI, 0.202-0.778; P = 0.007) was significantly associated with decreased risk of in-hospital mortality. Subgroup analysis further indicated that the association between B2A use and mortality was significant only in patients with HF without chronic pulmonary disease (OR, 2.427; 95% CI, 1.351-4.362; P = 0.003), but not in those with chronic pulmonary disease (OR, 2.094; 95% CI, 0.582-7.537; P = 0.258).In ICU patients with HF but without chronic pulmonary disease, the use of inhaled B2As is associated with increased in-hospital mortality.

A Cohort Study to Evaluate the Risk of Hospitalisation for Congestive Heart Failure Associated with the Use of Aclidinium and Other Chronic Obstructive Pulmonary Disease Medications in the UK Clinical Practice Research Datalink

BACKGROUND

The long-acting anticholinergic (LAMA) aclidinium was approved in Europe in 2012 to relieve symptoms in adults with chronic obstructive pulmonary disease (COPD). A Post-Authorisation Safety Study (PASS) was initiated to assess potential cardiovascular safety concerns for aclidinium.

OBJECTIVE

To estimate the adjusted incidence rate ratio (IRR) for hospitalisation for heart failure in patients with COPD who were new users of aclidinium, tiotropium, other LAMA, long-acting beta-agonists/inhaled corticosteroids (LABA/ICS), and LAMA/LABA were compared with initiators of LABA.

METHODS

This population-based cohort study included patients with COPD aged ≥40 years initiating COPD medications in the Clinical Practice Research Datalink (CPRD) GOLD in the United Kingdom from 2012 to 2017. Medications were identified via general practice prescriptions. The first-ever hospitalisations for heart failure were identified in the Hospital Episode Statistics, and general practitioner records from the CPRD. Poisson regression models were used to estimate the IRR for hospitalisation for heart failure in users of COPD medications versus LABA, adjusting for clinically relevant covariates.

RESULTS

The study included 4350 new users of aclidinium, 23,405 of tiotropium, 6977 of other LAMAs, 3122 of LAMA/LABA, 26,093 of LABA/ICS, and 5678 of LABA. Mean age was 69-70 years across medication groups. Aclidinium users had the highest proportion of severe COPD, and LABA users had the lowest (35% vs 19%, respectively). Crude incidence rates per 1000 person-years for the first-ever hospitalisation for heart failure ranged from 6.9 in LABA to 9.5 in aclidinium. Using LABA as reference, adjusted IRRs (95% confidence interval) for first-ever hospitalisation for heart failure were 0.90 (0.53-1.53) for aclidinium, 1.02 (0.69-1.51) for tiotropium, 0.86 (0.50-1.47) for other LAMAs, 1.09 (0.41-2.92) for LAMA/LABA, and 1.01 (0.69, 1.48) for LABA/ICS.

CONCLUSION

The study did not find increased risks of hospitalisations for heart failure in new users of aclidinium, tiotropium, other LAMAs, LAMA/LABA, and LABA/ICS compared with LABA.

Clinical Characteristics and Outcomes of Patients With Heart Failure With Reduced Ejection Fraction and Chronic Obstructive Pulmonary Disease: Insights From PARADIGM-HF

Background

Chronic obstructive pulmonary disease (COPD) is a common comorbidity in heart failure with reduced ejection fraction, associated with undertreatment and worse outcomes. New treatments for heart failure with reduced ejection fraction may be particularly important in patients with concomitant COPD.

Methods and Results

We examined outcomes in 8399 patients with heart failure with reduced ejection fraction, according to COPD status, in the PARADIGM‐HF (Prospective Comparison of Angiotensin Receptor Blocker–Neprilysin Inhibitor With Angiotensin‐Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. Cox regression models were used to compare COPD versus non‐COPD subgroups and the effects of sacubitril/valsartan versus enalapril. Patients with COPD (n=1080, 12.9%) were older than patients without COPD (mean 67 versus 63 years; P<0.001), with similar left ventricular ejection fraction (29.9% versus 29.4%), but higher NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide; median, 1741 pg/mL versus 1591 pg/mL; P=0.01), worse functional class (New York Heart Association III/IV 37% versus 23%; P<0.001) and Kansas City Cardiomyopathy Questionnaire–Clinical Summary Score (73 versus 81; P<0.001), and more congestion and comorbidity. Medical therapy was similar in patients with and without COPD except for beta‐blockade (87% versus 94%; P<0.001) and diuretics (85% versus 80%; P<0.001). After multivariable adjustment, COPD was associated with higher risks of heart failure hospitalization (hazard ratio [HR], 1.32; 95% CI, 1.13–1.54), and the composite of cardiovascular death or heart failure hospitalization (HR, 1.18; 95% CI, 1.05–1.34), but not cardiovascular death (HR, 1.10; 95% CI, 0.94–1.30), or all‐cause mortality (HR, 1.14; 95% CI, 0.99–1.31). COPD was also associated with higher risk of all cardiovascular hospitalization (HR, 1.17; 95% CI, 1.05–1.31) and noncardiovascular hospitalization (HR, 1.45; 95% CI, 1.29–1.64). The benefit of sacubitril/valsartan over enalapril was consistent in patients with and without COPD for all end points.

Conclusions

In PARADIGM‐HF, COPD was associated with lower use of beta‐blockers and worse health status and was an independent predictor of cardiovascular and noncardiovascular hospitalization. Sacubitril/valsartan was beneficial in this high‐risk subgroup.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01035255.

A mini review of inhaled beta 2 agonists in acute decompensated heart failure requiring respiratory support

Acute decompensated heart failure (HF) results in over one million hospital admissions per year, many requiring invasive or noninvasive mechanical ventilation for respiratory/cardiovascular support. Inhaled beta-2 adrenergic receptor agonists have been shown to be effective at clearance of extravascular lung water in HF patients. However, studies done in the late 1990s and early 2000s, prior to standardization and wide adoption of guideline directed medical therapy for HF, suggested that inhaled beta-2 agonist use increased admissions for HF exacerbations as well as in-hospital mortality. One study even attempted to utilize intravenous Beta-2 agonists in Acute Respiratory Distress Syndrome patients, however the study was stopped prematurely due to an 11% increased mortality in the treatment group. More recently however, studies examining patients who have concurrent diagnoses of chronic obstructive pulmonary disease (COPD) and HF showed that beta-2 agonist therapy resulted in similar or better outcomes compared to controls. Likewise, in-vitro studies, animal models, and studies utilizing chronic heart failure patients treated with nebulized beta-2 agonists with no concurrent respiratory diagnosis had a therapeutic effect of treatment over controls. These studies have the advantage of being performed with the standardization of guideline directed HF medical therapy. In conclusion, while we continue to recommend the use of Beta-2 agonist therapy in patients with concurrent COPD and HF requiring respiratory support, further studies, preferably single or double blinded prospective trials, will need to be performed to determine whether Beta-2 agonist therapy offers morbidity and mortality benefits in patients with strictly acute decompensated heart failure requiring respiratory support.

Bronchodilators in subjects with asthma-related comorbidities

Asthma is often associated with different comorbidities such as cardiovascular diseases, depression, diabetes mellitus, dyslipidaemia, osteoporosis, rhinosinusitis and mainly gastro-oesophageal reflux disease and allergic rhinitis. Although bronchodilators play an important role in the treatment of asthma, there is no overall description of their impact on comorbid asthma, regardless of whether favourable or negative. This narrative review examines the potential effects of bronchodilators on comorbidities of asthma.

Therapeutic effects of the combination of inhaled beta2-agonists and beta-blockers in COPD patients with cardiovascular disease

Chronic obstructive pulmonary disease (COPD) is a major health problem worldwide, with co-morbidities contributing to the overall severity and mortality of the disease. The incidence and prevalence of cardiovascular disease among COPD patients are high. Both disorders often co-exist, mainly due to smoking, but they also share common underlying risk factors, such as aging and low-grade systemic inflammation. The therapeutic approach is based on agents, whose pharmacological properties are completely opposed. Beta2-agonists remain the cornerstone of COPD treatment due to their limited cardiac adverse effects. On the other hand, beta-blockers are administered in COPD patients with cardiovascular disease, but despite their proven cardiac benefits, they remain underused. There is still a trend among physicians over underprescription of these drugs in patients with heart failure and COPD due to bronchoconstriction. Therefore, cardioselective beta-blockers are preferred, and recent meta-analyses have shown reduced rates in mortality and exacerbations in COPD patients treated with beta-blockers.

Reduced longitudinal cardiac strain in asthma patients

OBJECTIVE

There is limited knowledge about the potential relationship between asthma and heart function. Aim of our present study was to examine if asthma may be associated with manifest or subclinical heart dysfunction.

METHODS

Seventy-two allergic mild-to-moderate and severe asthma patients and 20 matched controls were enrolled in the study. Depending on the anti-asthmatic therapy, four subgroups of asthma patients were created: patients under long-acting beta2-agonists (LABA) and inhaled cortisone without oral cortisone treatment with (1a) versus without (1b) additional omalizumab therapy; patients with LABA, inhaled cortisone and omalizumab treatment with (2a) versus without (2b) oral cortisone. Standard echocardiographic parameters as well as global longitudinal left and right ventricular strains as determined by ultrasound-based speckle-tracking method were evaluated. Furthermore, NT-pro-brain natriuretic peptide (NT-pro-BNP), immunoglobulin E (IgE), C-reactive protein (CRP), and blood count were assessed in asthma and control groups.

RESULTS

There were no relevant differences in standard echocardiographic measures between both asthma groups and the control collective. Longitudinal left ventricular strain values were reduced significantly in severe and mild-to-moderate asthma groups (-12.91 ± 0.84% and -13.92 ± 1.55%, respectively), whereas longitudinal right ventricular strain values were additionally relevantly decreased in severe asthma (-10.35 ± 1.04%) compared to the control (-16.55 ± 0.49% and -18.48 ± 1.90%, respectively). Cardiac strains were similar in subgroups 1a and 1b. In contrast, patients from subgroup 2a presented reduced heart strains and decreased lung function compared to those from 2b. CRP, IgE, and eosinophils were significantly increased in asthma versus control individuals.

CONCLUSIONS

Allergic asthma, especially severe asthma is associated with subclinical impaired left and right ventricular function as determined by speckle-tracking analysis.

Korean Guidelines for Diagnosis and Management of Chronic Heart Failure

The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea. 
The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.

Chronic Obstructive Pulmonary Disease and Cardiac Diseases. An Urgent Need for Integrated Care

Chronic obstructive pulmonary disease (COPD) is a global health issue with high social and economic costs. Concomitant chronic cardiac disorders are frequent in patients with COPD, likely owing to shared risk factors (e.g., aging, cigarette smoke, inactivity, persistent low-grade pulmonary and systemic inflammation) and add to the overall morbidity and mortality of patients with COPD. The prevalence and incidence of cardiac comorbidities are higher in patients with COPD than in matched control subjects, although estimates of prevalence vary widely. Furthermore, cardiac diseases contribute to disease severity in patients with COPD, being a common cause of hospitalization and a frequent cause of death. The differential diagnosis may be challenging, especially in older and smoking subjects complaining of unspecific symptoms, such as dyspnea and fatigue. The therapeutic management of patients with cardiac and pulmonary comorbidities may be similarly challenging: bronchodilators may have cardiac side effects, and, vice versa, some cardiac medications should be used with caution in patients with lung disease. The aim of this review is to summarize the evidence of the relationship between COPD and the three most frequent and important cardiac comorbidities in patients with COPD: ischemic heart disease, heart failure, and atrial fibrillation. We have chosen a practical approach, first summarizing relevant epidemiological and clinical data, then discussing the diagnostic and screening procedures, and finally evaluating the impact of lung-heart comorbidities on the therapeutic management of patients with COPD and heart diseases.

Use of ICS/LABA (extra-fine and non-extra-fine) in elderly asthmatics

Age represents an exclusion criterion in randomized clinical trials designed to test the efficacy and safety of inhaled drugs in asthma. As a consequence, data on efficacy and safety of inhaled corticosteroid (ICS) and long-acting β2 agonist (LABA) combinations in elderly asthmatics are scanty. Older age is associated with an increased proportion of comorbid conditions; in addition, all organ functions undergo a process of senescence, thus reducing their ability to metabolize the agents. Overall, these age-associated conditions may variably, and often unpredictably, affect the metabolism and excretion of respiratory drugs. However, pharmacological treatment of asthma does not follow specific recommendations in the elderly. In the elderly, the ICS/LABA combinations may carry an increased risk of local indesiderable effects, primarily due to the lack of coordination between activation of the device and inhalation, and systemic adverse events, mainly due to the greater amount of active drug that is available because of the age-associated changes in organ functions as well as drug-to-drug and drug-to-concomitant disease interactions. The extra-fine formulations of ICSs/LABAs, which allow for a more favorable drug deposition in the lungs at a reduced dose, may contribute to overcome this issue. This review revises the efficacy and safety of treatment with ICSs/LABAs, focusing on the main pharmacodynamic and pharmacokinetic properties of the drugs and highlighting the potential risks in the elderly asthmatic population.

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.

Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.

Challenges in the pharmacological treatment of geriatric asthma

Asthma in older populations is characterized by frequent comorbid conditions, which increase the risk of side effects and of detrimental interactions between respiratory and non-respiratory drugs. These observations lead to the need to manage asthma in older populations by applying a multidimensional assessment and a multidisciplinary treatment; therefore, we favor the use of the 'geriatric' term to define asthma in the elderly. Geriatric asthma is a complex disease, which may not necessarily imply that it is also complicated, although the two conditions may often coexist. On this basis, the switch from an organ-driven management to the holistic approach may be the key factor to attain optimal control of the disease in this age range. The current review discusses the age-related factors affecting asthma treatment in the oldest individuals, such as the comorbid conditions, and age-related changes of metabolism and excretion that can impair the efficacy and safety of drugs.

Cardiac effects of current treatments of chronic obstructive pulmonary disease

We review the cardiac safety of the drugs available at present for the maintenance treatment of chronic obstructive pulmonary disease (COPD) in stable disease, focusing on inhaled long-acting muscarinic antagonists (LAMA) and long-acting β2 agonists (LABA), used either as a monotherapy or as a fixed-dose combination. We report the difficulties of, and pitfalls in, the investigation of the safety of drug treatments in COPD, which is hampered by the so-called COPD trial paradox: on the one hand, COPD is defined as a systemic disease and is frequently associated with comorbidities (especially cardiovascular comorbidities), which have an important effect on the prognosis of individual patients; on the other hand, patients with COPD and cardiovascular or other coexisting illnesses are often excluded from participation in randomised controlled clinical trials. In these trials, inhaled long-acting bronchodilators, both LAMA or LABA, or both, seem to be safe when used in the appropriate dose in adherent patients with COPD without uncontrolled cardiovascular disease or other notable comorbidities. However, the cardiac safety of LAMA and LABA is less evident when used inappropriately (eg, overdosing) or in patients with COPD and substantial cardiovascular disease, prolonged QTc interval, or polypharmacy. Potential warnings about rare cardiac events caused by COPD treatment from meta-analyses and observational studies need to be confirmed in high quality large randomised controlled trials. Finally, we briefly cover the cardiac safety issues of chronic oral drug treatments for COPD, encompassing theophylline, phosphodiesterase inhibitors, and macrolides.

Therapeutic approaches of uncomplicated arterial hypertension in patients with COPD

The concomitant presence of systemic arterial hypertension and chronic obstructive pulmonary disease (COPD) is frequent. Indeed, arterial hypertension is the most common comorbid disease in COPD patients. Since many antihypertensive drugs can act on airway function the treatment of arterial hypertension in COPD patients appears complex. Moreover, in these patients, a combined therapy is required for the adequate control of blood pressure. Currently, available data are inconsistent and not always comparable. Therefore the aim of this review is to analyze how antihypertensive drugs can affect airway function in order to improve the clinical management of hypertensive patients with COPD. Thiazide diuretics and calcium channel blockers appear the first-choice pharmacological treatment for these patients.

Multimorbidity and COPD Medication Receipt Among Medicaid Beneficiaries With Newly Diagnosed COPD

BACKGROUND

Multimorbidity is highly prevalent among patients with COPD. The association between multimorbidity and COPD medication management is not well researched. The aim of this study was to examine the association between multimorbidity and COPD medication receipt among Medicaid beneficiaries with newly diagnosed COPD.

METHODS

A retrospective longitudinal dynamic cohort design was used, and data were extracted from Medicaid Analytic eXtract files from 2005 to 2008. Medicaid beneficiaries with newly diagnosed COPD (N = 19,060) were identified using the International Classification of Diseases, 9th Revision, Clinical Modification, for COPD. This code (for commonly co-occurring conditions with COPD) was used to create a multimorbidity variable. These conditions included anxiety, arthritis, bipolar disorder, cardiovascular diseases, depression, diabetes, hypertension, hyperlipidemia osteoporosis, and schizophrenia. Medicaid beneficiaries with newly diagnosed COPD were categorized as: (1) physical multimorbidity only, (2) psychiatric multimorbidity only, (3) both physical and psychiatric multimorbidity, and (4) no multimorbidity. Receipt of COPD medications (short- or long-acting bronchodilators, inhaled corticosteroids) was identified using National Drug Codes. Bivariate relationships between multimorbidity and COPD medication receipt were tested using the chi-square test of independence. The associations between multimorbidity and COPD medication receipt were analyzed with logistic and multinomial logistic regression analyses.

RESULTS

Among Medicaid beneficiaries with newly diagnosed COPD, 81.9% had at least one co-occurring chronic condition. After controlling for subject characteristics, adults with multimorbidity were less likely to receive COPD medications compared with those without any inflammation-related multimorbidity. For example, those with physical multimorbidity were less likely to receive short-acting bronchodilators (adjusted odds ratio [OR] 0.76, 95% CI 0.69-0.83), long-acting bronchodilators (adjusted OR 0.84, 95% CI 0.76-0.92), and inhaled corticosteroids (adjusted OR 0.75, 95% CI 0.68-0.82) compared with those with no inflammation-related multimorbidity.

CONCLUSIONS

The prevalence of multimorbidity is very high among Medicaid beneficiaries with newly diagnosed COPD. Our findings indicate poor COPD medication management among those with multimorbidity.

Combination antihypertensive therapy among patients with COPD

BACKGROUND

COPD and hypertension both increase the risk of congestive heart failure (CHF). Current clinical trials do not inform the selection of combination antihypertensive therapy among patients with COPD. We performed a comparative effectiveness study to investigate whether choice of dual agent antihypertensive therapy is associated with risk of hospitalization for CHF among patients with these two conditions.

METHODS

We identified a cohort of 7,104 patients with COPD and hypertension receiving care within Veterans Administration hospitals between January 2001 and December 2006, with follow-up through April 2009. We included only patients prescribed two antihypertensive medications. We used Cox proportional hazard models for statistical analysis.

RESULTS

Compared with β-blockers plus an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, patients prescribed a thiazide diuretic plus a β-blocker (adjusted hazard ratio [HR], 0.49; 95% CI, 0.32-0.75), a thiazide plus an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (adjusted HR, 0.50; 95% CI, 0.35-0.71), and a thiazide plus a calcium channel blocker (adjusted HR, 0.55; 95% CI, 0.35-0.88) had a significantly lower risk of hospitalization for CHF. After stratification by history of CHF, we found that this association was isolated to patients without a history of CHF. Adjustment for patient characteristics and comorbidities had a small effect on risk of hospitalization. Choice of antihypertensive medication combination had no significant association with risk of COPD exacerbation.

CONCLUSIONS

Among patients with comorbid hypertension and COPD requiring two antihypertensive agents, combination therapy that includes a thiazide diuretic was associated with a significantly lower risk of hospitalization for CHF among patients without a history of CHF.

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.

Beta-blocker use and COPD mortality: a systematic review and meta-analysis

Background

Despite the benefits of beta-blockers in patients with established or sub-clinical coronary artery disease, their use in patients with chronic obstructive pulmonary disease (COPD) has been controversial. Currently, no systematic review has examined the impact of beta-blockers on mortality in COPD.

Methods

We systematically searched electronic bibliographic databases including MEDLINE, EMBASE and Cochrane Library for clinical studies that examine the association between beta-blocker use and all cause mortality in patients with COPD. Risk ratios across studies were pooled using random effects models to estimate a pooled relative risk across studies. Publication bias was assessed using a funnel plot.

Results

Our search identified nine retrospective cohort studies that met the study inclusion criteria. The pooled relative risk of COPD related mortality secondary to beta-blocker use was 0.69 (95% CI: 0.62-0.78; I₂=82%).

Conclusion

The results of this review are consistent with a protective effect of beta-blockers with respect to all cause mortality. Due to the observational nature of the included studies, the possibility of confounding that may have affected these results cannot be excluded. The hypothesis that beta blocker therapy might be of benefit in COPD needs to be evaluated in randomised controlled trials.

Pharmacology and therapeutics of bronchodilators

Bronchodilators are central in the treatment of of airways disorders. They are the mainstay of the current management of chronic obstructive pulmonary disease (COPD) and are critical in the symptomatic management of asthma, although controversies around the use of these drugs remain. Bronchodilators work through their direct relaxation effect on airway smooth muscle cells. at present, three major classes of bronchodilators, β(2)-adrenoceptor (AR) agonists, muscarinic receptor antagonists, and xanthines are available and can be used individually or in combination. The use of the inhaled route is currently preferred to minimize systemic effects. Fast- and short-acting agents are best used for rescue of symptoms, whereas long-acting agents are best used for maintenance therapy. It has proven difficult to discover novel classes of bronchodilator drugs, although potential new targets are emerging. Consequently, the logical approach has been to improve the existing bronchodilators, although several novel broncholytic classes are under development. An important step in simplifying asthma and COPD management and improving adherence with prescribed therapy is to reduce the dose frequency to the minimum necessary to maintain disease control. Therefore, the incorporation of once-daily dose administration is an important strategy to improve adherence. Several once-daily β(2)-AR agonists or ultra-long-acting β(2)-AR-agonists (LABAs), such as indacaterol, olodaterol, and vilanterol, are already in the market or under development for the treatment of COPD and asthma, but current recommendations suggest the use of LABAs only in combination with an inhaled corticosteroid. In addition, some new potentially long-acting antimuscarinic agents, such as glycopyrronium bromide (NVA-237), aclidinium bromide, and umeclidinium bromide (GSK573719), are under development, as well as combinations of several classes of long-acting bronchodilator drugs, in an attempt to simplify treatment regimens as much as possible. This review will describe the pharmacology and therapeutics of old, new, and emerging classes of bronchodilator.

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.

Are beta2-agonists responsible for increased mortality in heart failure?

AIMS

Previous large-scale, retrospective studies have shown increased mortality in heart failure (HF) patients using β2-agonists (B2As). We further examined the relationship between B2A use and mortality in a well-characterized population by adjusting for natriuretic peptide levels as a measure of HF severity.

METHODS AND RESULTS

This was a retrospective cohort study of patients attending an HF Disease Management Programme with mean follow-up of 2.9 ± 2.4 years. Chart review confirmed B2A use, dose and duration of use, and documented pulmonary function evaluation. The primary endpoint was the effect of B2A use compared with no B2A use on mortality using unadjusted and adjusted Kaplan-Meier survival curves. Data were available for 1294 patients (age 70.6 ± 11.5 years) of whom 64% were male and 22.2% were taking B2As. β2-Agonist users were older, more likely to be male, to have smoked, to have chronic obstructive pulmonary disease (COPD) and asthma, and less likely to take beta-blockers. Multivariable associates of mortality included: B-type natriuretic peptide (BNP), coronary artery disease, age, and beta-blocker use. Unadjusted mortality rates for B2A users were found to be significantly higher than non-B2A users [hazard ratio (HR) 1.304, 95% confidence interval (CI) 1.030-1.652, P= 0.028]. However, when adjusted for age, sex, medication, co-morbidity, smoking, COPD, and BNP differences, overall mortality rates were similar [HR 1.043, 95% CI (0.771-1.412), P= 0.783].

CONCLUSION

Unlike previous reports, this retrospective evaluation of B2A therapy in HF patients shows no relationship with long-term mortality when adjusted for population differences including BNP.  Large, prospective studies are required to define the risk/benefit ratio of B2As in patients with heart failure.

Recent trends in the characteristics and prognosis of patients hospitalized with acute heart failure

Background

Despite the magnitude and impact of heart failure (HF) in the United States, relatively little data are available that describe the prognosis associated with acute HF, especially from the perspective of a population-based investigation. The purpose of this nonconcurrent prospective study was to describe the overall, and changing trends therein, prognosis of 4228 patients discharged from all eleven greater Worcester (MA) medical centers after a documented episode of acute HF and factors associated with an increased risk of dying after hospital discharge.

Methods

The study population consisted of residents of the Worcester metropolitan area discharged after being hospitalized for acute HF at all greater Worcester medical centers during 1995 (n = 1783) and 2000 (n = 2445).

Results

The 3-month (20% versus 18%), 1-year (41% versus 38%), and 5-year (84% versus 82%) death rates were lower in patients discharged from all metropolitan Worcester hospitals in 2000 versus 1995, respectively. Improving long-term survival rates for patients discharged in 2000 as compared with 1995 were magnified after controlling for several confounding demographic and clinical factors of prognostic importance. A number of potentially modifiable demographic, medical history, and clinical factors were associated with an increased risk of dying during the first year after hospital discharge for acute HF.

Conclusion

The results of this community-wide observational study suggest improving trends in the long-term prognosis after acute HF. Despite these encouraging trends, the long-term prognosis for patients with acute HF remains poor, and several at-risk groups can be identified for early intervention and increased monitoring efforts.

Long-acting beta-agonists in the management of chronic obstructive pulmonary disease: current and future agents

Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation and debilitating symptoms. For patients with moderate-to-severe COPD, long-acting bronchodilators are the mainstay of therapy; as symptoms progress, guidelines recommend combining bronchodilators from different classes to improve efficacy. Inhaled long-acting β2-agonists (LABAs) have been licensed for the treatment of COPD since the late 1990s and include formoterol and salmeterol. They improve lung function, symptoms of breathlessness and exercise limitation, health-related quality of life, and may reduce the rate of exacerbations, although not all patients achieve clinically meaningful improvements in symptoms or health related quality of life. In addition, LABAs have an acceptable safety profile, and are not associated with an increased risk of respiratory mortality, although adverse effects such as palpitations and tremor may limit the dose that can be tolerated. Formoterol and salmeterol have 12-hour durations of action; however, sustained bronchodilation is desirable in COPD. A LABA with a 24-hour duration of action could provide improvements in efficacy, compared with twice-daily LABAs, and the once-daily dosing regimen could help improve compliance. It is also desirable that a new LABA should demonstrate fast onset of action, and a safety profile at least comparable to existing LABAs.A number of novel LABAs with once-daily profiles are in development which may be judged against these criteria. Indacaterol, a LABA with a 24-hour duration of bronchodilation and fast onset of action, is the most advanced of these. Preliminary results from large clinical trials suggest indacaterol improves lung function compared with placebo and other long-acting bronchodilators. Other LABAs with a 24-hour duration of bronchodilation include carmoterol, vilanterol trifenatate and oldaterol, with early results indicating potential for once-daily dosing in humans.The introduction of once-daily LABAs also provides the opportunity to develop combination inhalers of two or more classes of once-daily long-acting bronchodilators, which may be advantageous for COPD patients through simplification of treatment regimens as well as improvements in efficacy. Once-daily LABAs used both alone and in combination with long-acting muscarinic antagonists represent a promising advance in the treatment of COPD, and are likely to further improve outcomes for patients.

Inhaled albuterol/salbutamol and ipratropium bromide and their combination in the treatment of chronic obstructive pulmonary disease

IMPORTANCE OF THE FIELD

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality throughout the world. Combination therapy with albuterol and ipratropium bromide was approved > 15 years ago for the treatment of COPD. We review the mechanism of action, clinical efficacy, and safety of albuterol, ipratropium and combined albuterol-ipratropium therapy.

AREAS COVERED IN THIS REVIEW

We conducted a PubMed literature search using the keywords COPD, albuterol, ipratropium bromide and Combivent (Boehringer Ingelheim Corp., Ridgefield, CT, USA); pertinent references within the identified citations are included in the review. Data from the manufacturers are also evaluated.

WHAT THE READER WILL GAIN

At the time of its approval, albuterol/ipratropium bromide was an innovative combination of existing medications for the treatment of COPD. The combined formulation provides better improvement in airflow than either component alone and, by reducing the number of separate inhalers, simplifies therapy and improves compliance compared with the individual components.

TAKE HOME MESSAGE

The recent development and approval of longer acting and more potent beta agonists, anticholinergics and newer combination treatments have surpassed many of the advantages of combined albuterol-ipratropium for the treatment of patients with stable COPD.

Cardiovascular morbidity and the use of inhaled bronchodilators

We used the Manitoba Health database to examine the relationship between use of inhaled respiratory drugs in people with chronic obstructive respiratory diseases and cardiovascular hospitalizations from 1996 through 2000. The drugs examined were beta agonists [BA], ipratropium bromide IB, and inhaled steroids (ICS). End points were first hospitalizations for supraventricular tachycardia, myocardial infarction, heart failure or stroke. A nested case control analysis was employed comparing people with and without cardiovascular events. Cases and controls were matched for gender and age, and conditional logistic regression was used in multivariate analysis considering other respiratory drugs, respiratory diagnosis and visit frequency, non-respiratory, non-cardiac comorbidities, and receipt of drugs for cardiovascular disease. In univariate analyses, BA, IB and ICS were all associated with hospitalizations for cardiovascular disease, but in multivariate analyses ICS did not increase risk while both BA and IB did. There were interactions between respiratory and cardiac drugs receipt in that bronchodilator associated risks were higher in people not taking cardiac drugs; this was especially true for stroke. There were strong interactions with specific cardiac drugs; for example, both BA and IB substantially increased the risk of supraventricular tachycardia in patients not anti-arryhthmic agents, but not in the presence of such agents. We conclude that bronchodilator therapy for chronic obstructive diseases is associated with increased cardiovascular risk, especially in patients without previous cardiovascular diagnoses, and that this is unlikely due to the severity of the respiratory disease, since risk was not increased with ICS.

Cardiac safety of formoterol 12 microg twice daily in patients with chronic obstructive pulmonary disease

BACKGROUND

Some evidence suggests an increased risk of myocardial infarction and dysrhythmia events associated with beta(2)-agonist use in patients with chronic obstructive pulmonary disease (COPD). This prospective, multicenter, randomized, double-blind, placebo-controlled study compared the cardiac safety of formoterol and placebo in patients with COPD.

METHODS

After a 3-14-day run-in, 204 patients were randomized to receive formoterol 12 microg dry powder inhalation or matching placebo twice daily for 8 weeks. Twenty four-hour continuous electrocardiography (Holter monitoring) was performed at screening and after 2 and 8 weeks of treatment.

RESULTS

Only a small number of patients met the predefined criteria for a proarrhythmic event (4 formoterol and 2 placebo patients). No patients had sustained postbaseline ventricular tachycardia events, postbaseline run of ventricular ectopic beats associated with relevant symptoms (e.g. hypotension, syncope), or an episode of ventricular flutter or fibrillation. Holter monitoring data were variable but showed no clinically meaningful differences between the formoterol and placebo groups, respectively, for variables such as (mean+/-SD at end of treatment): heart rate (80+/-8.6 vs. 80+/-10.6 bpm), number and rate of ventricular premature beats (total 732+/-2685.4 vs. 650+/-2090.6; rate 35+/-131.0 vs. 30+/-101.3 per h), ventricular tachycardia events (total 0.4+/-1.70 vs. 1.0+/-9.23; rate 0.02+/-0.082 vs. 0.05+/-0.479 per h), and supraventricular premature beats (total 504+/-1844.1 vs. 823+/-2961.8; rate 22+/-80.6 vs. 37+/-129.6 per h). Vital signs and electrocardiogram data, including corrected QT intervals (Bazett and Fridericia), were similar across treatment groups. The overall adverse event experience was similar in the formoterol (n=26 [27%]) and placebo (n=33 [31%]) groups. The most common adverse events, infections and respiratory events, were expected for this patient population. The incidence of cardiac adverse events was low (1 formoterol and 4 placebo patients).

CONCLUSIONS

The results of this study confirm the good cardiovascular safety profile of formoterol in patients with COPD.

Inhaled beta2-adrenoceptor agonists: cardiovascular safety in patients with obstructive lung disease

Although large surveys have documented the favourable safety profile of beta(2)-adrenoceptor agonists (beta(2)-agonists) and, above all, that of the long-acting agents, the presence in the literature of reports of adverse cardiovascular events in patients with obstructive airway disease must induce physicians to consider this eventuality. The coexistence of beta(1)- and beta(2)-adrenoceptors in the heart clearly indicates that beta(2)-agonists do have some effect on the heart, even when they are highly selective. It should also be taken into account that the beta(2)-agonists utilised in clinical practice have differing selectivities and potencies. beta(2)-agonist use has, in effect, been associated with an increased risk of myocardial infarction, congestive heart failure, cardiac arrest and sudden cardiac death. Moreover, patients who have either asthma or chronic obstructive pulmonary disease may be at increased risk of cardiovascular complications because these diseases amplify the impact of these agents on the heart and, unfortunately, are a confounding factor when the impact of beta(2)-agonists on the heart is evaluated. Whatever the case may be, this effect is of particular concern for those patients with underlying cardiac conditions. Therefore, beta(2)-agonists must always be used with caution in patients with cardiopathies because these agents may precipitate the concomitant cardiac disease.