The Effect of Perioperative β-blockade on the Pulmonary Function of Patients Undergoing Major Arterial Surgery

Beta-blockers and health-related quality of life in patients with peripheral arterial disease and COPD

Background:

Beta-blockers are frequently withheld in patients with cardiovascular disease who also have chronic obstructive pulmonary disease (COPD) because of concerns that they might provoke bronchospasm and cause deterioration in health status. Although beta1-selective beta-blockers are associated with reduced mortality in COPD patients, their effects on health status are unknown. The aim of this study was to investigate the relationship between beta-blockers and health-related quality of life (HRQOL) in patients with peripheral arterial disease and COPD.

Methods:

Of the original cohort of 3371 vascular surgery patients, 1310 had COPD of whom 469 survived during long-term follow-up. These COPD patients were sent the Short Form-36 (SF-36) health-related quality of life questionnaire, which was completed and returned by 326 (70%) patients.

Results:

No significant differences in any of the SF-36 domains were observed between COPD patients who did and did not use beta-blockers (p > 0.05 for all). Furthermore, beta-blockers were not associated with any impairment in HRQOL among patients with COPD.

Conclusion:

Beta-blockers had no material impact on the HRQOL of patients with peripheral arterial disease who also had COPD. This suggests that beta-blockers can, in most circumstances, be administered to patients with COPD without impairment in HRQOL.

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

RATIONALE

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

OBJECTIVES

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

METHODS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Use of beta-adrenoceptor antagonists in older patients with chronic obstructive pulmonary disease and cardiovascular co-morbidity: safety issues

The incidence of and mortality from both chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) increase with age. In addition, the average age of patients with COPD and CVD is also increasing as a result of improvements in both pharmacological and non-pharmacological treatments. Coronary artery disease is a compelling indication for beta-adrenoceptor antagonist use in a population in whom beta-adrenoceptor antagonism is often viewed as contraindicated. beta-Adrenoceptor antagonists have been proven to improve cardiovascular morbidity and mortality but have been under-utilized in patients with COPD with concomitant CVD because of a fear of bronchoconstriction and adverse effects, particularly in the elderly. The advanced age of patients with COPD and CVD, along with the sheer number of patients with these diseases, necessitates that clinicians understand the treatment of these co-morbidities using seemingly conflicting therapy in the form of beta-adrenoceptor agonists and antagonists. We review changes in the pharmacokinetics and pharmacodynamics of beta-adrenoceptor antagonists in the elderly, the role of beta-adrenoceptor antagonists in CVD and the literature regarding the safety and mortality benefits of beta-adrenoceptor antagonists in elderly patients with COPD and concomitant CVD. We conclude that cardioselective beta-adrenoceptor antagonists appear to be safe to use in elderly male patients with mild-to-moderate COPD who have a compelling indication for beta-adrenoceptor antagonist therapy. Data in female patients are very limited. Nonselective beta-adrenoceptor antagonists should be avoided in general, except in patients with heart failure who might benefit significantly from the use of carvedilol. beta-Adrenoceptor antagonists have been shown to improve mortality in older patients with coexisting CVD and COPD.

Surgery in older people: an update

In the past two decades, the rate of surgery in older people has increased more rapidly than the rate of aging of the population, so both a larger proportion and a greater number of older people are now undergoing surgery. This may partly reflect a cultural change in surgery and anaesthesia with respect to a greater willingness to undertake elective procedures in older people, although there remain areas where they have less access to surgery than do younger patients. For instance, older people are less likely to undergo operative procedures after a cancer diagnosis. Furthermore, in those who do have surgery, resection rate (i.e. curative therapy) is lower than in younger people with equivalent tumour stages, and even more so in older patients with COPD, cardiovascular disease or diabetes. This article explores the complex relationship between age and surgical outcome, provides an evidence-based overview of risk assessment and common postoperative problems in older people, and summarizes good practice points (at times necessarily pragmatic) for clinical management of the older surgical patient. There has been a substantial expansion in the literature examining risks, outcomes and interventions in older surgical patients since the previous review article of this subject published in this journal. Although we do not cover anaesthesia in older people, the review of that topic remains relevant. The American Society of Anaesthesiologists' Classification of Risk which illustrates that risk is disease- rather than age- based, is shown in Table 1. Most publications examine elective rather than emergency surgery in older people (with the exception of hip fracture), and this is reflected in the content of the paper.