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Can Adherence to and Persistence with Inhaled Long-acting Bronchodilators Improve the Quality of Life in Patients with Chronic Obstructive Pulmonary Disease? Results from a German Disease Management Program. Clin Drug Investig 2021; 41:989-998. [PMID: 34637102 DOI: 10.1007/s40261-021-01083-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE: Adherence to and persistence with inhaled long-acting bronchodilators (ILAB), is commonly considered to be a relevant driver of perceived health-related quality of life (HRQoL) in chronic obstructive pulmonary disease (COPD), but the topic is rarely studied with real-world data. Using survey and health insurance claims data, this study investigates the effect of adherence to and persistence with ILAB on EQ-5D-5L visual analog scale (VAS) in ILAB users who were enrolled in the German disease management programs (DMP) for COPD. METHODS Included ILAB users were aged ≥ 18 years, continuously insured with AOK Bavaria and enrolled in the DMP for COPD. Adherence to ILAB [proportion of days covered (PDC); PDC ≥ 80%], and persistence (days of uninterrupted ILAB therapy) were assessed in the year preceding the study's HRQoL questionnaire. In a cross-sectional design we applied quasi-Poisson models with log link function and subgroup analyses. The robustness of results was analyzed with comprehensive sensitivity analyses. RESULTS Patients with PDC ≥ 80% had 2.96% higher VAS scores than patients with lower PDCs. From all analyses, patients with GOLD stage III had the highest effects from PDC ≥ 80% (5.33% increased VAS). Patients without heart failure profited significantly more from PDC ≥ 80% (+ 4.34% vs - 2.88%) and from an additional persistent day (+ 0.01% vs - 0.01%) than patients with heart failure. CONCLUSIONS Overall, ILAB users significantly profited from PDC ≥ 80%, but not from continuous PDC or persistent days. In secondary subgroup analyses, patients with GOLD stage III and patients without heart failure particularly profited from PDC ≥ 80%. Only patients without heart failure particularly profited from more persistent days. Because identified effects were small and often not robust, advancing adherence and persistence alone may not improve the German DMP for COPD substantially.
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Abstract
Acute decompensated heart failure (ADHF) is one of the leading admission diagnoses worldwide, yet it is an entity with incompletely understood pathophysiology and limited therapeutic options. Patients admitted for ADHF have high in-hospital morbidity and mortality, as well as frequent rehospitalizations and subsequent cardiovascular death. This devastating clinical course is partly due to suboptimal medical management of ADHF with persistent congestion upon hospital discharge and inadequate predischarge initiation of life-saving guideline-directed therapies. While new drugs for the treatment of chronic HF continue to be approved, there has been no new therapy approved for ADHF in decades. This review will focus on the current limited understanding of ADHF pathophysiology, possible therapeutic targets, and current limitations in expanding available therapies in light of the unmet need among these high-risk patients.
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Affiliation(s)
- Joyce N. Njoroge
- Division of Cardiology, School of Medicine, University of California San Francisco (J.N.N., J.R.T.), San Francisco, CA
| | - John R. Teerlink
- Division of Cardiology, School of Medicine, University of California San Francisco (J.N.N., J.R.T.), San Francisco, CA
- Section of Cardiology, San Francisco Veterans Affairs Medical Center (J.R.T.), San Francisco, CA
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3
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Xing G, Woo AYH, Pan L, Lin B, Cheng MS. Recent Advances in β 2-Agonists for Treatment of Chronic Respiratory Diseases and Heart Failure. J Med Chem 2020; 63:15218-15242. [PMID: 33213146 DOI: 10.1021/acs.jmedchem.0c01195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
β2-Adrenoceptor (β2-AR) agonists are widely used as bronchodilators. The emerge of ultralong acting β2-agonists is an important breakthrough in pulmonary medicine. In this review, we will provide mechanistic insights into the application of β2-agonists in asthma, chronic obstructive pulmonary disease (COPD), and heart failure (HF). Recent studies in β-AR signal transduction have revealed opposing functions of the β1-AR and the β2-AR on cardiomyocyte survival. Thus, β2-agonists and β-blockers in combination may represent a novel strategy for HF management. Allosteric modulation and biased agonism at the β2-AR also provide a theoretical basis for developing drugs with novel mechanisms of action and pharmacological profiles. Overlap of COPD and HF presents a substantial clinical challenge but also a unique opportunity for evaluation of the cardiovascular safety of β2-agonists. Further basic and clinical research along these lines can help us develop better drugs and innovative strategies for the management of these difficult-to-treat diseases.
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Affiliation(s)
- Gang Xing
- Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China.,Key Laboratory of Structure-Based Drug Design and Discovery of Ministry of Education, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Anthony Yiu-Ho Woo
- Department of Pharmacology, School of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Li Pan
- Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China.,Key Laboratory of Structure-Based Drug Design and Discovery of Ministry of Education, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Bin Lin
- Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China.,Key Laboratory of Structure-Based Drug Design and Discovery of Ministry of Education, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Mao-Sheng Cheng
- Department of Medicinal Chemistry, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, Shenyang 110016, China.,Key Laboratory of Structure-Based Drug Design and Discovery of Ministry of Education, Shenyang Pharmaceutical University, Shenyang 110016, China
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4
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Iyngkaran P, Liew D, Neil C, Driscoll A, Marwick TH, Hare DL. Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2018; 12:1179546818809358. [PMID: 30618487 PMCID: PMC6299336 DOI: 10.1177/1179546818809358] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 09/14/2018] [Indexed: 12/20/2022]
Abstract
This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.
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Affiliation(s)
- Pupalan Iyngkaran
- Northern Territory Medical Program, Flinders University, Darwin, NT, Australia
- Pupalan Iyngkaran, Yellow Building 4 Cnr University Drive North & University Drive West Charles Darwin University, Casuarina, NT 0815, Australia.
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Christopher Neil
- Department of Medicine—Western Precinct, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrea Driscoll
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
- Austin Health, Melbourne, VIC, Australia
| | | | - David L Hare
- Cardiovascular Research, The University of Melbourne, Melbourne, VIC, Australia
- Heart Failure Services, Austin Health, Melbourne, VIC, Australia
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5
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Petta V, Perlikos F, Loukides S, Bakakos P, Chalkias A, Iacovidou N, Xanthos T, Tsekoura D, Hillas G. Therapeutic effects of the combination of inhaled beta2-agonists and beta-blockers in COPD patients with cardiovascular disease. Heart Fail Rev 2018; 22:753-763. [PMID: 28840400 DOI: 10.1007/s10741-017-9646-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Vasiliki Petta
- Medical School, Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", National and Kapodistrian University of Athens, Athens, Greece.
| | - Fotis Perlikos
- Pulmonary Division, Department of Critical Care, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Department of Respiratory Medicine, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, Athens, Greece
| | - Petros Bakakos
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, Medical School, Sotiria University Hospital, Athens, Greece
| | - Athanasios Chalkias
- Medical School, Postgraduate Study Program (MSc) "Cardiopulmonary Resuscitation", National and Kapodistrian University of Athens, Athens, Greece
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Nicoletta Iacovidou
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
- Department of Neonatology, National and Kapodistrian University of Athens, Medical School, Aretaieio University Hospital, Athens, Greece
| | - Theodoros Xanthos
- Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
- European University Cyprus, School of Medicine, Nicosia, Cyprus
| | - Dorothea Tsekoura
- Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Aretaieio University Hospital, Athens, Greece
| | - Georgios Hillas
- Pulmonary Division, Department of Critical Care, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
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6
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Caravita S, Vachiéry JL. Obstructive Ventilatory Disorder in Heart Failure-Caused by the Heart or the Lung? Curr Heart Fail Rep 2016; 13:310-318. [PMID: 27817003 DOI: 10.1007/s11897-016-0309-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Heart failure (HF) is a clinical syndrome frequently associated with airway obstruction, either as a respiratory comorbidity or as a direct consequence of HF pathophysiology. Recognizing the relative contribution of an underlying airway disease as opposed to airway obstruction due to volume overload and left atrial pressure elevation is of importance for the appropriate management of patients affected by HF. This review focuses on "les liaisons dangereuses" between the heart and the lungs, outlying recent advances linking in a vicious circle of chronic obstructive lung disease (COPD) and obstructive sleep apnea (OSA) on one side and HF on the other side. It also discusses the role of pivotal diagnostic tools such as pulmonary function tests and cardiopulmonary exercise test to determine the contribution of HF and COPD to symptoms and clinical status. Treatment implications are discussed as well.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Pulmonary Hypertension and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Jean-Luc Vachiéry
- Pulmonary Hypertension and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium. .,Department of Cardiology, CUB Hôpital Erasme, 808 Route de Lennik, 1070, Brussels, Belgium.
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7
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Alajaji W, Baydoun A, Al-Kindi SG, Henry L, Hanna MA, Oliveira GH. Digoxin therapy for cor pulmonale: A systematic review. Int J Cardiol 2016; 223:320-324. [DOI: 10.1016/j.ijcard.2016.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022]
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8
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Hopper I, Kotecha D, Chin KL, Mentz RJ, von Lueder TG. Comorbidities in Heart Failure: Are There Gender Differences? Curr Heart Fail Rep 2016; 13:1-12. [DOI: 10.1007/s11897-016-0280-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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9
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Siniorakis E, Arvanitakis S, Tzevelekos P, Panta S, Zampelis C, Aivalioti F, Rentoukas E. Hypertensive heart disease and bronchodilators: Potential left ventricular outflow obstruction. Int J Cardiol 2015; 196:123-4. [DOI: 10.1016/j.ijcard.2015.04.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
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10
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Exercise intolerance in heart failure with preserved ejection fraction: more than a heart problem. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2015; 12:294-304. [PMID: 26089855 PMCID: PMC4460174 DOI: 10.11909/j.issn.1671-5411.2015.03.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 04/03/2015] [Accepted: 04/10/2015] [Indexed: 12/20/2022]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF in older adults, and is increasing in prevalence as the population ages. Furthermore, HFpEF is increasing out of proportion to HF with reduced EF (HFrEF), and its prognosis is worsening while that of HFrEF is improving. Despite the importance of HFpEF, our understanding of its pathophysiology is incomplete, and optimal treatment remains largely undefined. A cardinal feature of HFpEF is reduced exercise tolerance, which correlates with symptoms as well as reduced quality of life. The traditional concepts of exercise limitations have focused on central dysfunction related to poor cardiac pump function. However, the mechanisms are not exclusive to the heart and lungs, and the understanding of the pathophysiology of this disease has evolved. Substantial attention has focused on defining the central versus peripheral mechanisms underlying the reduced functional capacity and exercise tolerance among patients with HF. In fact, physical training can improve exercise tolerance via peripheral adaptive mechanisms even in the absence of favorable central hemodynamic function. In addition, the drug trials performed to date in HFpEF that have focused on influencing cardiovascular function have not improved exercise capacity. This suggests that peripheral limitations may play a significant role in HF limiting exercise tolerance, a hallmark feature of HFpEF.
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11
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Cooper LB, Mentz RJ. COPD in heart failure: are there long-term implications following acute heart failure hospitalization? Chest 2015; 147:586-588. [PMID: 25732437 DOI: 10.1378/chest.14-2081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Lauren B Cooper
- Duke Clinical Research Institute and the Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Robert J Mentz
- Duke Clinical Research Institute and the Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC.
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12
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Abstract
There are still many aspects of heart failure care for which gaps remain in the evidence base, resulting in gaps in the guidelines. We aim to highlight these guideline gaps including areas that warrant further research and other areas where new data are forthcoming.
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Affiliation(s)
- Bao Tran
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles,California, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles,California, USA
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13
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Noncardiac comorbidities in heart failure with reduced versus preserved ejection fraction. J Am Coll Cardiol 2014; 64:2281-93. [PMID: 25456761 DOI: 10.1016/j.jacc.2014.08.036] [Citation(s) in RCA: 383] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 08/19/2014] [Accepted: 08/28/2014] [Indexed: 01/09/2023]
Abstract
Heart failure patients are classified by ejection fraction (EF) into distinct groups: heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Although patients with heart failure commonly have multiple comorbidities that complicate management and may adversely affect outcomes, their role in the HFpEF and HFrEF groups is not well-characterized. This review summarizes the role of noncardiac comorbidities in patients with HFpEF versus HFrEF, emphasizing prevalence, underlying pathophysiologic mechanisms, and outcomes. Pulmonary disease, diabetes mellitus, anemia, and obesity tend to be more prevalent in HFpEF patients, but renal disease and sleep-disordered breathing burdens are similar. These comorbidities similarly increase morbidity and mortality risk in HFpEF and HFrEF patients. Common pathophysiologic mechanisms include systemic and endomyocardial inflammation with fibrosis. We also discuss implications for clinical care and future HF clinical trial design. The basis for this review was discussions between scientists, clinical trialists, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum.
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Faludi R. [Chronic obstructive pulmonary disease: a cardiologist's point of view]. Orv Hetil 2014; 155:1480-4. [PMID: 25194870 DOI: 10.1556/oh.2014.29989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chronic obstructive pulmonary disease is often associated with cardiovascular diseases, such as pulmonary hypertension, ischemic heart disease, arrhythmias or heart failure. These co-morbidities may cause diagnostic or therapeutic difficulties and significantly worsen the morbidity and mortality of patients with chronic obstructive pulmonary disease. In this work the author reviews special considerations for the treatment of patients with chronic obstructive pulmonary disease who have cardiovascular co-morbidities.
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Affiliation(s)
- Réka Faludi
- Pécsi Tudományegyetem Szívgyógyászati Klinika Pécs Ifjúság u. 13. 7624
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15
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Zafar MA, Droege C, Foertsch M, Panos RJ. Update on ultra-long-acting β agonists in chronic obstructive pulmonary disease. Expert Opin Investig Drugs 2014; 23:1687-701. [PMID: 25139313 DOI: 10.1517/13543784.2014.942730] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION For the last two decades, long-acting β agonists (LABAs) have been a cornerstone in the management of chronic obstructive pulmonary disease (COPD). They relax airway smooth muscle and augment expiratory airflow, which reduces hyperinflation and improves dyspnea, functional capacity and quality of life. In recent years, Indacaterol, a LABA with an ultra-long duration of action (ultra-LABA), which only requires once-daily dosing, was approved by the FDA. The clinical efficacy of indacaterol is comparable, and, in some aspects better, than the currently available LABAs. AREAS COVERED This article reviews the pharmacological properties, clinical efficacy, safety and potential role of the ultra-LABAs in COPD management. EXPERT OPINION Ultra-LABAs are effective bronchodilators with a prolonged duration of action. By decreasing dosing frequency, ultra-LABAs potentially may improve respiratory medication adherence, which is associated with better survival and less healthcare utilization. In addition to their salubrious benefits, β agonists may produce untoward effects. Increased mortality and hospitalizations among patients with left ventricular heart failure, who were treated with β agonists, has caused concern about their use in patients with COPD and heart disease. Further experience and testing will determine the optimal role of ultra-LABAs in the management of COPD.
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Affiliation(s)
- Muhammad Ahsan Zafar
- University of Cincinnati Medical Center, Division of Pulmonary and Critical Care Medicine , 1 Albert Sabin Way, MSB Room 6053, Mail Location 0564, Cincinnati, OH 45267 , USA
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Mentz RJ, Cotter G, Cleland JGF, Stevens SR, Chiswell K, Davison BA, Teerlink JR, Metra M, Voors AA, Grinfeld L, Ruda M, Mareev V, Lotan C, Bloomfield DM, Fiuzat M, Givertz MM, Ponikowski P, Massie BM, O'Connor CM. International differences in clinical characteristics, management, and outcomes in acute heart failure patients: better short-term outcomes in patients enrolled in Eastern Europe and Russia in the PROTECT trial. Eur J Heart Fail 2014; 16:614-24. [PMID: 24771609 DOI: 10.1002/ejhf.92] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/05/2014] [Accepted: 03/07/2014] [Indexed: 01/04/2023] Open
Abstract
AIMS The implications of geographical variation are unknown following adjustment for hospital length of stay (LOS) in heart failure (HF) trials that included patients whether or not they had systolic dysfunction. We investigated regional differences in an international acute HF trial. METHODS AND RESULTS The PROTECT trial investigated 2033 patients with acute HF and renal dysfunction hospitalized at 173 sites in 17 countries with randomization to rolofylline or placebo. We grouped enrolling countries into six regions. Baseline characteristics, in-hospital management, and outcomes were explored by region. The primary study outcome was 60-day mortality or cardiovascular/renal hospitalization. Secondary outcomes included 180-day mortality. Of 2033 patients, 33% were from Eastern Europe, 19% from Western Europe, 16% from Israel, 15% from North America, 14% from Russia, and 3% from Argentina. Marked differences in baseline characteristics, HF phenotype, in-hospital diuretic and vasodilator strategies, and LOS were observed by region. LOS was shortest in North America and Israel (median 5 days) and longest in Russia (median 15 days). Regional event rates varied significantly. Following multivariable adjustment, region was an independent predictor of the risk of mortality/hospitalization at 60 days, with the lowest risk in Russia (hazard ratio 0.39, 95% confidence interval 0.23-0.64 vs. Western Europe) due to lower rehospitalization; mortality differences were attenuated by 180 days. CONCLUSIONS In an international HF trial, there were differences in baseline characteristics, treatments, LOS, and rehospitalization amongst regions, but little difference in longer term mortality. Rehospitalization differences exist independent of LOS. This analysis may help inform future trial design and should be externally validated.
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Puente-Maestu L, Calle M, Ortega-González A, Fuster A, González C, Márquez-Martín E, Marcos-Rodriguez PJ, Calero C, Rodríguez-Hermosa JL, Malo de Molina R, Aburto M, Sobradillo P, Alcázar B, Tirado-Conde G. Multicentric study on the beta-blocker use and relation with exacerbations in COPD. Respir Med 2014; 108:737-44. [PMID: 24635914 DOI: 10.1016/j.rmed.2014.02.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 12/11/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is frequently associated with chronic heart failure (CHF) or coronary artery disease (CAD). In spite of the recommendation to use beta-blockers (BB) they are likely under-prescribed to patients with concurrent COPD and heart diseases. To find out the prevalence of use of BB, 256 COPD patients were consecutively recruited by pulmonary physicians from 14 hospitals in 7 regions of Spain in their outpatient offices if they had a diagnosis of COPD, were not on long-term oxygen therapy, had CHF or CAD, and met the criteria for BB treatment. In patients with indication 58% (95%CI, 52-64%) of the COPD patients and 97% of the non-COPD patients were on BB (p < 0.001). In patients with COPD, several factors were independently related to at least one visit to the emergency room in the previous year such as use of BB, adjusted OR = 0.27 (95% CI 0.15-0.50), GOLD stage D, OR = 2.52 (1.40-4.53), baseline heart rate >70, OR 2.19 (1.24-3.86) use of long-acting beta2-agonists OR = 2.18 (1.29-3.68), previous episodes of left ventricular failure OR 2.27 (1.19-4.33) and diabetes, OR = 1.82 (1.08-3.38). We conclude that, according to what is recommended by current guidelines, BB are still under-prescribed in COPD patients. COPD patients with CHF or CAD using BB suffer fewer exacerbations and visits to the ER. GOLD stage, use of long-acting beta2-agonists, baseline heart rate and comorbidities are also risk factors for exacerbations in this population.
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Affiliation(s)
- Luis Puente-Maestu
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain.
| | - Myriam Calle
- Servicio de Neumología, Hospital Clínico San Carlos, Madrid, Spain
| | - Angel Ortega-González
- Unidad de Neumología, Hospital General Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Antonia Fuster
- Servicio de Neumología, Hospital Son Llàtzer (Palma de Mallorca), Spain
| | - Cruz González
- Servicio de Neumología, Hospital Clínico Universitario, Valencia, Spain
| | - Eduardo Márquez-Martín
- Unidad Médico Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, Spain; Instituto de Biomedicina de Sevilla (IBIS), Spain; Universidad Hispalense, Sevilla, Spain
| | | | - Carmen Calero
- Unidad Médico Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, Spain; Instituto de Biomedicina de Sevilla (IBIS), Spain
| | | | | | | | | | - Bernardino Alcázar
- Neumología, Agencia Sanitaria Poniente Hospital de Alta Resolución de Loja, Granada, Spain
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Abstract
There are still many aspects of heart failure care for which gaps remain in the evidence base, resulting in gaps in the guidelines. We aim to highlight these guideline gaps including areas that warrant further research and other areas where new data are forthcoming.
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Affiliation(s)
- Bao Tran
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, California, US
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, California, US
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19
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Tavazzi L, Swedberg K, Komajda M, Böhm M, Borer JS, Lainscak M, Robertson M, Ford I. Clinical profiles and outcomes in patients with chronic heart failure and chronic obstructive pulmonary disease: an efficacy and safety analysis of SHIFT study. Int J Cardiol 2013; 170:182-8. [PMID: 24225201 DOI: 10.1016/j.ijcard.2013.10.068] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/27/2013] [Accepted: 10/19/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Heart failure (HF) and chronic obstructive pulmonary disease (COPD) frequently coexist, with undefined prognostic and therapeutic implications. We investigated clinical profile and outcomes of patients with chronic HF and COPD, notably the efficacy and safety of ivabradine, a heart rate-reducing agent. METHODS 6505 ambulatory patients, in sinus rhythm, heart rate ≥ 70 bpm and stable systolic HF were randomised to placebo or ivabradine (2.5 to 7.5mg bid). Multivariate Cox model analyses were performed to compare the COPD (n=730) and non-COPD subgroups, and the ivabradine and placebo treatment effects. RESULTS COPD patients were older and had a poorer risk profile. Beta-blockers were prescribed to 69% of COPD patients and 92% of non-COPD patients. The primary endpoint (PEP) and its component, hospitalisation for worsening HF, were more frequent in COPD patients (HRs f, 1.22 [p=0.006]; and 1.34 [p<0.001]) respectively, but relative risk was reduced similarly by ivabradine in both COPD (14%, and 17%) and non-COPD (18% and 27%) patients (p interaction=0.82, and 0.53, respectively). Similar effect was noted also for cardiovascular death. Adverse events were more common in COPD patients, but similar in treatment subgroups. Bradycardia occurred more frequently in ivabradine subgroups, with similar incidence in patients with or without COPD. CONCLUSIONS The association of COPD and HF results in a worse prognosis, and COPD represents a barrier to optimisation of beta-blocker therapy. Ivabradine is similarly effective and safe in chronic HF patients with or without COPD, and can be safely combined with beta-blockers in COPD.
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Affiliation(s)
- L Tavazzi
- Maria Cecilia Hospital, GVM Care & Research, Ettore Sansavini Health Science Foundation, Cotignola, Italy.
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Minasian AG, van den Elshout FJ, Dekhuijzen PR, Vos PJ, Willems FF, van den Bergh PJ, Heijdra YF. Reply to letter to the Editor. Heart Lung 2013; 42:388-9. [DOI: 10.1016/j.hrtlng.2013.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hawkins NM, Virani S, Ceconi C. Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services. Eur Heart J 2013; 34:2795-803. [PMID: 23832490 DOI: 10.1093/eurheartj/eht192] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Nathaniel M Hawkins
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
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Jenkins C, Beasley R. Authors' reply to 'explaining differential effects of tiotropium on mortality in COPD'. Thorax 2013; 68:590-1. [PMID: 23802285 DOI: 10.1136/thoraxjnl-2013-203238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
The acute heart failure (AHF) population is a heterogeneous group with multiple interrelated noncardiovascular comorbidities. Chronic obstructive pulmonary disease, renal disease, diabetes, sleep apnea, and anemia affect the clinical characteristics and outcomes of patients with AHF and complicate inpatient management. This article summarizes the impact of these noncardiovascular comorbidities in patients with AHF. In some circumstances, careful attention to the diagnosis and management of these conditions in patients with AHF may help to improve patient outcomes.
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Affiliation(s)
- Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.
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Association of beta-blocker use and selectivity with outcomes in patients with heart failure and chronic obstructive pulmonary disease (from OPTIMIZE-HF). Am J Cardiol 2013. [PMID: 23200803 DOI: 10.1016/j.amjcard.2012.10.041] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In patients with heart failure (HF) with chronic obstructive pulmonary disease (COPD), concerns exist regarding β blockers, particularly noncardioselective β blockers, precipitating bronchospasm or attenuating the benefit of inhaled β(2) agonists. The aim of this study was to test the hypothesis that noncardioselective β blockers would not be associated with worse outcomes compared with cardioselective β blockers in patients with concomitant COPD in a large HF registry. A retrospective analysis of patients from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) who had systolic dysfunction, documentation of β-blocker status, and follow-up information available after index hospitalization (n = 2,670) was performed. The associations between cardioselective and noncardioselective β blockers and the end points of 60- to 90-day mortality and mortality or rehospitalization in patients with (n = 722) and without (n = 1,948) COPD were analyzed using regression modeling. The models were adjusted for covariate predictors of β-blocker use at discharge and clinical predictors of outcomes. Noncardioselective and cardioselective β blockers were associated with lower risk-adjusted mortality in patients with and without COPD. There was no evidence that β-blocker selectivity was associated with a difference in outcomes between patients with and those without COPD (p for interaction >0.10 for both outcomes). In conclusion, despite concerns regarding β blockers in patients with HF with COPD, there was no evidence that β-blocker selectivity was associated with differences in outcomes for patients with HF with COPD versus those without.
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Mentz RJ, Schulte PJ, Fleg JL, Fiuzat M, Kraus WE, Piña IL, Keteyian SJ, Kitzman DW, Whellan DJ, Ellis SJ, O'Connor CM. Clinical characteristics, response to exercise training, and outcomes in patients with heart failure and chronic obstructive pulmonary disease: findings from Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION). Am Heart J 2013; 165:193-9. [PMID: 23351822 DOI: 10.1016/j.ahj.2012.10.029] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 10/29/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to investigate the clinical characteristics, exercise training response, β-blocker selectivity, and outcomes in patients with heart failure (HF) and chronic obstructive pulmonary disease (COPD). METHODS We performed an analysis of HF-ACTION, which randomized 2,331 patients with HF having an ejection fraction of ≤35% to usual care with or without aerobic exercise training. We examined clinical characteristics and outcomes (mortality/hospitalization, mortality, cardiovascular [CV] mortality/CV hospitalization, and CV mortality/HF hospitalization) by physician-reported COPD status using adjusted Cox models and explored an interaction with exercise training. The interaction between β-blocker cardioselectivity and outcomes was investigated. RESULTS Of patients with COPD status documented (n = 2311), 11% (n = 249) had COPD. Patients with COPD were older, had more comorbidities, and had lower use of β-blockers compared with those without COPD. At baseline, patients with COPD had lower peak oxygen consumption and higher V(E)/V(CO)(2) slope. During a median follow-up of 2.5 years, COPD was associated with increased mortality/hospitalization, mortality, and CV mortality/HF hospitalization. After multivariable adjustment, the risk of CV mortality/HF hospitalization remained increased (hazard ratio [HR] 1.46, 95% CI 1.14-1.87), whereas mortality/hospitalization (HR 1.15, 95% CI 0.96-1.37) and mortality (HR 1.33, 95% CI 0.99-1.76) were not significantly increased. There was no interaction between COPD and exercise training on outcomes or between COPD and β-blocker selectivity on mortality/hospitalization (all P > .1). CONCLUSIONS Chronic obstructive pulmonary disease in patients with HF was associated with older age, more comorbidities, reduced exercise capacity, and increased CV mortality/HF hospitalization, but not a differential response to exercise training. β-Blocker selectivity was not associated with differences in outcome for patients with vs without COPD.
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Minasian AG, van den Elshout FJJ, Dekhuijzen PNR, Vos PJE, Willems FF, van den Bergh PJPC, Heijdra YF. Bronchodilator responsiveness in patients with chronic heart failure. Heart Lung 2012; 42:208-14. [PMID: 23273658 DOI: 10.1016/j.hrtlng.2012.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 11/21/2012] [Accepted: 11/21/2012] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of inhaled bronchodilators on pulmonary function and dyspnea in patients with chronic heart failure (HF). BACKGROUND Conflicting data exist on whether bronchodilators may improve pulmonary function and dyspnea in patients with chronic HF. METHODS In this retrospective observational study we analyzed data of 116 chronic HF outpatients with systolic dysfunction who underwent spirometry and Borg dyspnea measurements before and after inhalation of 400 μg salbutamol and 80 μg ipratropium. Patients with chronic obstructive pulmonary disease (COPD) or asthma were excluded. RESULTS Bronchodilators fully reversed airway obstruction (AO) in 25 of 64 (39.1%) patients with pre-bronchodilator AO. All spirometric measurements, except for forced vital and inspiratory capacities, improved significantly post-bronchodilation. Absolute and percent improvements in forced expiratory volume in 1 s (FEV1) were more pronounced in patients with persistent AO post-bronchodilation compared to those without AO (0.19 ± 0.18 L and 8.4 ± 7.3% versus 0.11 ± 0.12 L and 4.3 ± 4.0%, p < 0.05). Significant bronchodilator responsiveness of FEV1 (>200 mL and >12%) was noted in 12.1% and was more frequent in patients with persistent AO and fully reversible AO than in those without AO (23.1% and 16.0% versus 1.9%, p < 0.05). We measured a small, albeit significant improvement in dyspnea (0.7 ± 1.2 versus 0.9 ± 1.3, p = 0.002). CONCLUSIONS Inhaled bronchodilators may have an additional role in the management of patients with chronic HF because of their potential to improve pulmonary function, especially in those with AO. The clinical usefulness and possible adverse events of bronchodilators need to be further established.
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Affiliation(s)
- Armine G Minasian
- Department of Pulmonary Diseases, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands.
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