Tolerability of carvedilol in patients with heart failure and concomitant chronic obstructive pulmonary disease or asthma

Beta-Blockers in the Prevention and Treatment of Ischemic Heart Disease: Evidence and Clinical Practice

Coronary artery disease (CAD) is the most prevalent cardiovascular disease characterized by atherosclerotic plaque buildup that can lead to partial or full obstruction of blood flow in the coronary arteries. Treatment for CAD involves a combination of lifestyle changes, pharmacologic therapy, and modern revascularization procedures. Beta-adrenoceptor antagonists (or beta-blockers) have been widely used for decades as a key therapy for CAD. In this review, prior studies are examined to better understand beta-adrenoceptor antagonist use in patients with acute coronary syndrome, stable coronary heart disease, and in the perioperative setting. The evidence for the benefit of beta-blocker therapy is well established for patients with acute myocardial infarction, but it diminishes as the time from the index cardiac event elapses. The evidence for benefit in the perioperative setting is not strong.

Hypertension management in patients with cardiovascular comorbidities

Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.

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.

[Possibilities and limitations of the use of beta-blockers in patients with cardiovascular disease and chronic obstructive pulmonary disease]

In medical literature, increasing attention is paid to comorbidities in patients with chronic obstructive pulmonary disease (COPD). In clinical practice, physicians often hesitate to prescribe beta-blockers (β1-adrenoblockers) to COPD patients. This article summarized new results of using beta-blockers in patients with COPD. According to reports, the selective β1-blocker treatment considerably increases the survival rate of patients with COPD and ischemic heart disease, particularly after myocardial infarction (MI), and with chronic heart failure (CHF). The benefit of administering selective β1-blockers to patients with CHF and/or a history of MI overweighs a potential risk related with the treatment even in patients with severe COPD. Convincing data in favor of the β1-blocker treatment in COPD patients without the above-mentioned comorbidities are not available. At present, the selective β1-blocker treatment is considered safe for patients with cardiovascular diseases and COPD. For this reason, selective β1-blockers, such as bisoprolol, metoprolol or nebivolol can be used in managing this patient cohort. Nonselective β1-blockers may induce bronchospasm and are not recommended for COPD patients. For the treatment with β-blockers with intrinsic sympathomimetic activity, the probability of bronchial obstruction in COPD patients is lower; however, drugs of this pharmaceutical group have not been compared with cardioselective beta-blockers. For safety reasons, the beta-blocker treatment should be started outside exacerbation of COPD and from a small dose. Careful monitoring is recommended for possible new symptoms, such as emergence/increase of shortness of breath, cough or changes in dosing of other drugs (for example, increased frequency of using short-acting bronchodilators).

Beta Blockers and Chronic Obstructive Pulmonary Disease (COPD): Sum of Evidence

Approximately, half a century has passed since the discovery of beta blockers. Then, their prime therapeutic purpose was to treat angina and cardiac arrhythmias, nowadays, beta blockers' usage and effectiveness is extended to treat other cardiovascular diseases, such as hypertension, congestive heart failure, and coronary artery disease. Safety concerns were raised about beta blockers and their use for chronic obstructive pulmonary disease (COPD) patients with concurrent cardiovascular disease. After a thorough research of the literature, this review summarizes the evidence proving that beta blockers not only might be well tolerated in COPD patients, but they might also have a beneficial effect in this group of patients.

Choosing among β-blockers in heart failure patients according to β-receptors' location and functions in the cardiopulmonary system

Several large clinical trials showed a favorable effect of β-blocker treatment in patients with chronic heart failure (HF) as regards overall mortality, cardiovascular mortality, and hospitalizations. Indeed, the use of β-blockers is strongly recommended by current international guidelines, and it remains a cornerstone in the pharmacological treatment of HF. Although different types of β-blockers are currently approved for HF therapy, possible criteria to choose the best β-blocking agent according to HF patients' characteristics and to β-receptors' location and functions in the cardiopulmonary system are still lacking. In such a context, a growing body of literature shows remarkable differences between β-blocker types (β1-selective blockers versus β1-β2 blockers) with respect to alveolar-capillary gas diffusion and chemoreceptor response in HF patients, both factors able to impact on quality of life and, most likely, on prognosis. This review suggests an original algorithm for choosing among the currently available β-blocking agents based on the knowledge of cardiopulmonary pathophysiology. Particularly, starting from lung physiology and from some experimental models, it focuses on the mechanisms underlying lung mechanics, chemoreceptors, and alveolar-capillary unit impairment in HF. This paper also remarks the significant benefit deriving from the correct use of the different β-blockers in HF patients through a brief overview of the most important clinical trials.

β-Blockers and the Rate of Chronic Obstructive Pulmonary Disease Exacerbations

Objective: To review the rate of exacerbations relative to β-blocker use in patients with chronic obstructive pulmonary disease (COPD). Data Sources: A MEDLINE search (1953 to May 2019) was performed using the search terms beta-blockers, chronic obstructive pulmonary disease, and exacerbations. An EMBASE search was also performed using the search terms chronic obstructive lung disease and beta adrenergic receptor blocking agents (1970 to May 2019). References from the review of literature citations were also identified. Study Selection and Data Extraction: English-language studies assessing COPD exacerbations in patients prescribed a β-blocker were included. Any article not addressing exacerbations was excluded. Data Synthesis: A total of 15 articles were included; 7 articles showed no change, 1 provided mixed results, and 7 indicated a significant decrease in COPD exacerbations in a variety of exacerbation severities. Two of the studies differentiated between cardioselective and noncardioselective β-blockers. Relevance to Patient Care and Clinical Practice: This work represents an initial assessment of the use of β-blockers to reduce COPD exacerbations. The findings raise the question if β-blockers should be used more frequently in patients with COPD. Conclusions: Based on the limited number of studies that address β-blocker use in COPD, it appears that exacerbations are not increased and may be decreased. A randomized, placebo-controlled trial is in progress to possibly provide more definitive answers to this question. Until the trial is complete, β-blockers should not be withheld in COPD patients who have concurrent cardiovascular conditions, especially where there is a mortality benefit.

Acutely decompensated heart failure with chronic obstructive pulmonary disease: Clinical characteristics and long-term survival

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is among the most common comorbidities in patients hospitalized with heart failure and is generally associated with poor outcomes. However, the results of previous studies with regard to increased mortality and risk trajectories were not univocal. We sought to assess the prognostic impact of COPD in patients admitted for acutely decompensated heart failure (ADHF) and investigate the association between use of β-blockers at discharge and mortality in patients with COPD.

METHODS

We studied 1530 patients. The association of COPD with mortality was examined in adjusted Fine-Gray proportional hazard models where heart transplantation and ventricular assist device implantation were treated as competing risks. The primary outcome was 5-year all-cause mortality.

RESULTS

After adjusting for establisked risk markers, the subdistribution hazard ratios (SHR) of 5-year mortality for COPD patients compared with non-COPD patients was 1.25 (95% confidence intervals [CIs] 1.06-1.47; p = .007). The relative risk of death for COPD patients increased steeply from 30 to 180 days, and remained noticeably high throughout the entire follow-up. Among patients with comorbid COPD, the use of β-blockers at discharge was associated with a significantly reduced risk of 1-year post-discharge mortality (SHR 0.66, 95%CIs 0.53-0.83; p ≤.001).

CONCLUSIONS

Our data indicate that ADHF patients with comorbid COPD have a worse long-term survival than those without comorbid COPD. Most of the excess mortality occurred in the first few months following hospitalization. Our data also suggest that the use of β-blockers at discharge is independently associated with improved survival in ADHF patients with COPD.

Effect of beta-blocker therapy on clinical outcomes, safety, health-related quality of life and functional capacity in patients with chronic obstructive pulmonary disease (COPD): a protocol for a systematic literature review and meta-analysis with multiple treatment comparison

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) who have a clinical indication for beta-blocker therapy, are often not prescribed such medication, despite evidence suggesting that beta-blockers are not associated with adverse respiratory outcomes. The primary objective of this systematic review and meta-analysis is to examine the class effect of beta-blocker use in patients with COPD. We will focus on a broad range of endpoints including, clinical, safety, and patient-centric outcomes such as health related quality of life (HRQoL) and functional capacity. A secondary objective is to explore potential within-class variation in the effects of beta-blockers among patients with COPD, and rank individual agents according to their relative benefit(s).

METHODS AND ANALYSIS

MEDLINE, Embase, The Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases will be systematically searched, from inception to present, to identify randomised controlled trials (RCTs) and other prospective and interventional studies of beta-blocker use in patients with COPD which report on the outcomes of interest. Relative treatment effects with respect to mortality, COPD exacerbations, all-cause hospitalisation, lung function, HRQoL and exercise capacity will be summarised by meta-analysis. Individual treatments (agents) will be compared in a Bayesian network meta-analysis including RCT and observational data, if feasible.

ETHICS AND DISSEMINATION

The results of the study will be submitted for publication in a peer-reviewed journal. Only previously published aggregate data will be used for the purpose of this review.

PROSPERO REGISTRATION NUMBER

CRD42018098983.

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

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

β-Blockers, heart disease and COPD: current controversies and uncertainties

Treating people with cardiovascular disease and COPD causes significant clinician anxiety. β-Blockers save lives in people with heart disease, specifically postinfarction and heart failure. COPD and heart disease frequently coexist and people with both disorders have particularly high cardiovascular mortality. There are concerns about giving β-blockers to people with concomitant COPD that include reduced basal lung function, diminished effectiveness of emergency β-agonist treatments, reduced benefit of long-acting β-agonist treatment and difficulty in discriminating between asthma and COPD. β-Blockers appear to reduce lung function in both the general population and those with COPD because they are poorly selective for cardiac β1-adrenoceptors over respiratory β2-adrenoceptors, and studies have shown that higher β-agonist doses are required to overcome the β-blockade. COPD and cardiovascular disease share similar environmental risks and both disease states have high adrenergic and inflammatory activation. β-Blockers may therefore be particularly helpful in reducing cardiovascular events in this high-risk group. They may reduce the background inflammatory state, and inhibit the tachycardia and hypertension associated with both the endogenous adrenaline and high-dose β-agonist treatment associated with acute exacerbations of COPD. Some studies have suggested no increased and, at times, reduced mortality in patients with COPD taking β-blockers for heart disease. However, these are all observational studies and there are no randomised controlled trials. Potential ways to improve this dilemma include the development of highly β1-selective β-blockers or the use of non-β-blocking heart rate reducing agents, such as ivabridine, if these are proven to be beneficial in randomised controlled trials.

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.

Carvedilol binding to β2-adrenergic receptors inhibits CFTR-dependent anion secretion in airway epithelial cells

Carvedilol functions as a nonselective β-adrenergic receptor (AR)/α1-AR antagonist that is used for treatment of hypertension and heart failure. Carvedilol has been shown to function as an inverse agonist, inhibiting G protein activation while stimulating β-arrestin-dependent signaling and inducing receptor desensitization. In the present study, short-circuit current (Isc) measurements using human airway epithelial cells revealed that, unlike β-AR agonists, which increase Isc, carvedilol decreases basal and 8-(4-chlorophenylthio)adenosine 3',5'-cyclic monophosphate-stimulated current. The decrease in Isc resulted from inhibition of the cystic fibrosis transmembrane conductance regulator (CFTR). The carvedilol effect was abolished by pretreatment with the β2-AR antagonist ICI-118551, but not the β1-AR antagonist atenolol or the α1-AR antagonist prazosin, indicating that its inhibitory effect on Isc was mediated through interactions with apical β2-ARs. However, the carvedilol effect was blocked by pretreatment with the microtubule-disrupting compound nocodazole. Furthermore, immunocytochemistry experiments and measurements of apical CFTR expression by Western blot analysis of biotinylated membranes revealed a decrease in the level of CFTR protein in monolayers treated with carvedilol but no significant change in monolayers treated with epinephrine. These results demonstrate that carvedilol binding to apical β2-ARs inhibited CFTR current and transepithelial anion secretion by a mechanism involving a decrease in channel expression in the apical membrane.

[Medical therapy of heart and lung diseases. Effects on the respective other organ]

Many patients suffer from both heart and lung diseases. The choice of medical drugs should not only be driven by the clinical and prognostic effects on the target organ but should also be selected based on the effects on the respective other organ. Beta blockers and statins have both beneficial and harmful effects on the respiratory system. Angiotensin-converting enzyme (ACE) inhibitors and amiodarone can cause severe lung damage. Low-dose thiazides and calcium antagonists are first-line medications in hypertensive asthma patients but beta blockers should be avoided. Theophyline should be used with caution in patients with known cardiac disease. Glucocorticosteroids can cause cardiovascular symptoms while the phosphodiesterase inhibitor roflumilast appears to have no relevant cardiovascular side effects. Anticholinergic drugs have both favorable and unfavorable cardiovascular (side) effects. Short-acting beta-2 sympathomimetic drugs (SABA) and macrolides in particular can trigger arrhythmia and some SABAs are associated with a higher incidence of myocardial infarction. Detailed knowledge of the effects of drugs used for the treatment of lung and heart diseases on the respective other organ and the associated complications and long-term effects are essential in providing optimal medical care to the many patients who present with both respiratory and cardiovascular diseases.

Potential drug-drug interactions in hospitalized patients with chronic heart failure and chronic obstructive pulmonary disease

INTRODUCTION

Polypharmacy is common in patients with chronic heart failure (HF) and/or chronic obstructive pulmonary disease (COPD), but little is known about the prevalence and significance of drug-drug interactions (DDIs). This study evaluates DDIs in hospitalized patients.

MATERIAL AND METHODS

We retrospectively screened medical charts over a 6-month period for diagnosis of chronic HF and/or COPD. Potential DDIs were evaluated using Lexi-Interact software.

RESULTS

Seven hundred and seventy-eight patients were included in the study (median age 75 years, 61% men). The median number of drugs on admission and discharge was 6 (interquartile range (IQR) 4-9) and 7 (IQR 5-), respectively (p = 0.10). We recorded 6.5 ±5.7 potential DDIs per patient on admission and 7.2 ±5.6 on discharge (p = 0.2). From admission to discharge, type-C and type-X potential DDIs increased (p < 0.05 for both). Type X interactions were rare (< 1%), with the combination of a β-blocker and a β2 agonist being the most common (64%). There were significantly more type-C and type-D potential DDIs in patients with chronic HF as compared to patients with COPD (p < 0.001). Patients with concomitant chronic HF and COPD had more type-C and type-X potential DDIs when compared to those with individual disease (p < 0.005). An aldosterone antagonist and ACE inhibitor/ARB were prescribed to 3% of chronic HF patients with estimated glomerular filtration rate < 30 ml/(min × 1.73 m(2)).

CONCLUSIONS

The DDIs are common in patients with chronic HF and/or COPD, but only a few appear to be of clinical significance. The increase in potential DDIs from admission to discharge may reflect better guideline implementation rather than poor clinical practice.

Risk of emergent bradycardia associated with the use of carvedilol and metoprolol in routine clinical practice

BACKGROUND

Large randomized trials have reported mixed results regarding the risk of bradycardia between metoprolol and carvedilol. We compared the incidence of emergent bradycardia (measured by an emergency department visit or hospitalization due to bradycardia) for patients initiating metoprolol and carvedilol.

METHODS

Adult beneficiaries of Medi-Cal, the State of California Medicaid program, without a diagnosis of bradycardia who initiated metoprolol or carvedilol between May 1, 2004, and November 1, 2009, were included. Cox proportional hazard regression analysis was performed to model the time to first occurrence of emergent bradycardia after initiation of the study drugs as a dependent variable and the study drug (metoprolol vs carvedilol) as the primary predictor with adjustments for total daily metoprolol-equivalent dose, formulations, and use of nonstudy drugs as time-varying covariates, as well as demographics and comorbidities.

RESULTS

Among 38,186 subjects, 77.7% initiated metoprolol and 22.3% initiated carvedilol. The incidence of emergent bradycardia was low and comparable between the drugs (18.1 per 1000 person-years using metoprolol vs 17.7 per 100 person-years using carvedilol; unadjusted hazard ratio, 1.07; 95% confidence interval, 0.76-1.49). However, carvedilol users had substantially different population characteristics compared with metoprolol users. After adjustments for demographics, comorbidities, metoprolol-equivalent dose, formulations, and use of nonstudy drugs, initiation of metoprolol was associated with an increased risk of emergent bradycardia compared with that of carvedilol (adjusted hazard ratio, 1.64; 95% confidence interval, 1.14-2.36).

CONCLUSIONS

Initiation of metoprolol is associated with an increased risk of emergent bradycardia compared with carvedilol, although the overall incidence of emergent bradycardia is low in routine clinical practice.

Current perspectives on treatment of hypertensive patients with chronic obstructive pulmonary disease

Systemic hypertension and chronic obstructive pulmonary disease (COPD) frequently coexist in the same patient, especially in the elderly. Today, a wide variety of antihypertensive drugs with different mechanisms of action are available to the prescribing physician. In addition, combination drugs for hypertension are becoming increasingly popular. Certain antihypertensive drugs can affect pulmonary function. Therefore the management of such patients can present therapeutic challenges. We have examined the literature pertaining to the use of antihypertensive drugs in patients with systemic hypertension and coexisting COPD. Although data are often limited or of poor quality, we have attempted to review and then provide recommendations regarding the use of all the specific classes of antihypertensive drug therapies including combination drugs in patients with COPD. The antihypertensive agents reviewed include diuretics, aldosterone receptor blockers, beta blockers, combined alpha and beta blockers, angiotensin-converting enzyme inhibitors, angiotensin II antagonists, calcium channel blockers, alpha-1 blockers, centrally acting drugs, direct vasodilators, and combinations of these drugs. Of these classes, calcium channel blockers and angiotensin II antagonists appear to be the best initial choices if hypertension is the only indication for treatment. However, the limited data available on many of these drugs suggest that additional studies are needed to more precisely determine the best treatment choices in this widely prevalent patient group.

β-Blocker Use and Incidence of Chronic Obstructive Pulmonary Disease Exacerbations

BACKGROUND

β-Adrenergic antagonist (β-blocker) use in patients with chronic obstructive pulmonary disease (COPD) has been avoided as a result of potential risk of pulmonary adverse effects. However, recent studies indicate that β-blocker use in patients with COPD can decrease outpatient visits and either decrease or have no effect on the number of hospitalizations. Long-term treatment with β-blockers has been shown to increase survival and decrease exacerbations in patients with COPD.

OBJECTIVE

To assess the impact of β-blocker use on the incidence of exacerbations in patients with COPD.

METHODS

In a retrospective cohort study of patients with COPD from 2 academic primary care practice sites who were seen in 2010, patients were identified using International Classification of Diseases, 9th revision, Clinical Modification codes for COPD and reviewing active medication lists for COPD-specific medications (tiotropium). Patients were classified as either a β-blocker user or a nonuser. Primary outcomes were incidence and severity of COPD exacerbations. Secondary outcomes included COPD exacerbations distinguished by β-blocker cardioselectivity and all-cause hospitalizations.

RESULTS

The study enrolled 412 patients. Of those, 166 patients were β-blocker users and 246 were β-blocker nonusers. β-Blocker users were less likely to have a COPD exacerbation (OR 0.61, 95% CI 0.40–0.93) and had fewer mild exacerbations (OR 0.56; 95% CI 0.34–0.89). There was no significant difference in COPD exacerbations based on β-blocker cardioselectivity (OR 0.84, 95% CI 0.38–1.83). When controlled for, using a backwards stepwise logistic regression, β-blocker use was a variable in the model that predicted exacerbations but alone was not statistically significant (adjusted OR 0.62, 95% CI 0.39–1.01).

CONCLUSIONS

Patients with COPD prescribed a β-blocker were significantly less likely to have a COPD exacerbation and had fewer mild COPD exacerbations.

Coronary artery disease is under-diagnosed and under-treated in advanced lung disease

BACKGROUND

Coronary artery disease is a potentially treatable comorbidity observed frequently in both chronic obstructive pulmonary disease and interstitial lung disease. The prevalence of angiographically proven coronary artery disease in advanced lung disease is not well described. We sought to characterize the treatment patterns of coronary artery disease complicating advanced lung disease and to describe the frequency of occult coronary artery disease in this population.

METHODS

We performed a 2-center, retrospective cross-sectional study of patients with either chronic obstructive pulmonary disease or interstitial lung disease evaluated for lung transplantation. Medications and diagnoses before the transplant evaluation were recorded in conjunction with left heart catheterization results.

RESULTS

Of 473 subjects, 351 had chronic obstructive pulmonary disease, and 122 had interstitial lung disease. In subjects diagnosed clinically with coronary artery disease, medical regimens included a statin in 78%, antiplatelet therapy in 62%, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in 42%, and a beta-blocker in 37%. Ten percent were on no medication from these 4 classes. Fifty-seven percent of these subjects were on an antiplatelet agent as well as a statin, and 13% were on neither. Beta-blockers were less frequently prescribed in chronic obstructive pulmonary disease than interstitial lung disease (23% vs 58%, P=.007). Coronary angiography was available in 322 subjects. It demonstrated coronary artery disease in 60% of subjects, and severe coronary artery disease in 16%. Occult coronary artery disease and severe occult coronary artery disease were found in 53% and 9%, respectively. There were no significant differences in angiographic results between chronic obstructive pulmonary disease and interstitial lung disease, despite imbalanced risk factors.

CONCLUSIONS

Coronary artery disease is common in patients with advanced lung disease attributable to chronic obstructive pulmonary disease or interstitial lung disease and is under-diagnosed. Guideline-recommended cardioprotective medications are suboptimally utilized in this population.

β-blockade: benefits beyond blood pressure reduction?

Hypertension is a major cardiovascular (CV) risk factor, but several other common conditions, including chronic obstructive pulmonary disease (COPD), osteoporosis, and peripheral arterial disease (PAD), have been shown to independently increase the risk of CV events and death. The physiological basis for an increased CV risk in those conditions probably lies in the augmentations of oxidative stress, endothelial dysfunction, systemic inflammation, and arterial stiffness, which all are also hallmarks of hypertension. β-Blockers have been used for the treatment of hypertension for more than 40 years, but a number of meta-analyses have demonstrated that treatment with these agents may be associated with an increased risk of CV events and mortality. However, the majority of primary prevention β-blocker trials employed atenolol, an earlier-generation β(1) -selective blocker whose mechanism of action is based on a reduction of cardiac output. Available evidence suggests that vasodilatory β-blockers may be free of the deleterious effects of atenolol. The purpose of this review is to summarize pathophysiologic mechanisms thought to be responsible for the increased CV risk associated with COPD, osteoporosis, and PAD, and examine the possible benefits of vasodilatory β-blockade in those conditions. Our examination focused on nebivolol, a β(1) -selective agent with vasodilatory effects most likely mediated via β(3) activation.

Differences between bisoprolol and carvedilol in patients with chronic heart failure and chronic obstructive pulmonary disease: a randomized trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) frequently coexists in patients with chronic heart failure (CHF) and is a key factor for beta blocker underprescription and underdosing. This study compared effects of bisoprolol and carvedilol in patients with both conditions.

METHODS

This was a randomized open-label study, of bisoprolol and carvedilol during initiation and uptitration to target or maximal tolerated dose. Pulmonary function testing, 12-lead electrocardiogram, and N-terminal pro brain natriuretic peptide were measured at baseline and follow-up.

RESULTS

We randomized 63 elderly patients (73 ± 9 years, 81% men, left ventricular ejection fraction 33 ± 7%) with mild to moderate CHF (54% New York Heart Assocation class II) and moderate to severe COPD (76% Global initiative for chronic Obstructive Lung Disease stage 2). Target dose was tolerated by 31 (49%) patients and 19 (30%) patients experienced adverse events during follow-up (19% bisoprolol, 42% carvedilol, p = 0.045). Study medication had to be withdrawn in 8 (13%) patients (bisoprolol: 2 due to hypotension, 1 due to bradycardia; carvedilol: 2 due to hypotension and 1 due to wheezing, dyspnoea, and oedema, respectively). Forced expiratory volume in 1(st) second significantly increased in bisoprolol (1561 ± 414 ml to 1698 ± 519 ml, p = 0.046) but not carvedilol (1704 ± 484 to 1734 ± 548, p = 0.44) group. Both agents reduced heart rate (bisoprolol: 75 ± 14 to 68 ± 10, p = 0.007; carvedilol 78 ± 14 to 72 ± 12, p = 0.016) and had no effect on N-terminal pro brain natriuretic peptide.

CONCLUSIONS

Beta blockers frequently caused adverse events, and thus 49% of patients could tolerate the target dose. Bisoprolol induced demonstrable improvement in pulmonary function and caused less adverse events.

Carvedilol therapy after cocaine-induced myocardial infarction in patients with asthma

INTRODUCTION

Cocaine-induced myocardial infarction (MI) is well documented. Current literature recommends avoiding beta-blockers in the acute care setting, but after discharge from the hospital, benefits of beta-blocker use may outweigh risks in patients with recent MI resulting from cocaine use. Cardioselective beta-blocker therapy has been demonstrated to be beneficial in post-MI patients with nonsevere asthma. This review article is to compare the risks and benefits of using carvedilol in patients with asthma who have had cocaine-induced MI.

METHODS

The authors searched the English literature from 1984 to July 2010 via PubMed, EMBASE and SCOPUS using the following search terms: "cocaine-induced myocardial infarction AND treatment," "cocaine AND carvedilol," "beta blockers AND asthma," and "carvedilol AND asthma." All studies and case reports related to carvedilol use associated with bronchospasm in patients with asthma and carvedilol use after cocaine-induced MI were included.

RESULTS

Carvedilol has theoretical advantages in patients who use cocaine, but there are no controlled studies confirming the superior efficacy of this agent. Reports of carvedilol use in patients with asthma are rare, but findings include increased asthma symptoms and hospitalization in some patients. Fatal asthma has also been reported because of this noncardioselective beta-blocker.

CONCLUSIONS

Based on a lack of evidence supporting the theoretical advantages but documented risks associated with its use in patients with asthma, carvedilol should be avoided in asthma patients who have a history of cocaine-induced MI. Cardioselective beta-blockers should be used in post-MI patients with nonsevere asthma.

Evolution of β-blockers: from anti-anginal drugs to ligand-directed signalling

Sir James Black developed β-blockers, one of the most useful groups of drugs in use today. Not only are they being used for their original purpose to treat angina and cardiac arrhythmias, but they are also effective therapeutics for hypertension, cardiac failure, glaucoma, migraine and anxiety. Recent studies suggest that they might also prove useful in diseases as diverse as osteoporosis, cancer and malaria. They have also provided some of the most useful tools for pharmacological research that have underpinned the development of concepts such as receptor subtype selectivity, agonism and inverse agonism, and ligand-directed signalling bias. This article examines how β-blockers have evolved and indicates how they might be used in the future.

β-blockers and their mortality benefits: underprescribed in heart failure and chronic obstructive pulmonary disease

This article discusses the most recent insights into the actions of β-blockers on the heart and lungs, highlighting that β-blockers should have a place in the treatment of patients with chronic obstructive pulmonary disease (COPD), especially in those with coexisting cardiovascular disease or arterial hypertension. Practical studies clearly show underutilization of β-blockers in patients with heart failure and COPD, which seems to be caused by an unnecessary fear for adverse effects on the lungs, and the ‘outdated’ adverse effects mentioned on instruction leaflets.

The effect of evidence-based medication use on long-term survival in patients hospitalised for heart failure in Western Australia

OBJECTIVES

To examine trends and predictors of prescription medications on discharge after first (index) hospitalisation for heart failure (HF), and the effect on all-cause mortality of evidence-based therapy.

DESIGN

A retrospective multicentre cohort study, with medical record review.

SETTING

Three tertiary-care hospitals in Perth, Western Australia.

PATIENTS

WA Hospital Morbidity Data were used to identify a random sample of 1006 patients with an index admission to hospital for HF between 1996 and 2006.

MAIN OUTCOME MEASURES

Proportion of patients prescribed evidence-based therapy for HF on discharge from hospital; and 1-year all-cause mortality.

RESULTS

Among 944 patients surviving to hospital discharge, the prescription rate of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) (74.3%) and loop diuretics (85.5%) remained high over the study period, whereas that of beta-blockers and spironolactone increased (10.5% to 51.3% and 1.4% to 23.3%, respectively), and digoxin prescription decreased (38.1% to 20.7%). The temporal trends in use of beta-blockers, spironolactone and digoxin were in line with clinical trial evidence. Age > or = 75 years was a significant, negative predictor of beta-blocker and spironolactone prescription. In-hospital echocardiography, performed in 53% of patients, was associated with a significantly greater likelihood of treatment with ACE inhibitors/ARBs, beta-blockers and spironolactone. Both ACE inhibitors/ARBs and beta-blockers prescribed on discharge were associated with a lower adjusted hazard ratio (HR) for mortality at 1-year (HR, 0.71; P = 0.003; and HR, 0.68; P = 0.002, respectively).

CONCLUSION

ACE inhibitors/ARBs and beta-blockers, prescribed during initial hospitalisation for HF, are associated with improved long-term survival. Therapy became more evidence based over the study period, but echocardiography, an important predictor of evidence-based therapy, was underutilised.

Coexisting chronic obstructive pulmonary disease and heart failure: implications for treatment, course and mortality

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) and heart failure are prevalent comorbidities affecting a huge proportion of the world population, responsible for significant morbidity and mortality. Their coexistence is more frequent than previously recognized and poses important diagnostic and therapeutic challenges. Prognosis of patients with concurrent heart failure and COPD has not been comprehensively addressed. With this review, we intend to emphasize the diagnosis and prognosis implications of the two coexisting conditions and to highlight the therapeutic constraints posed by the combination.

RECENT FINDINGS

Progressively, more attention has been given to the interplay between COPD and heart failure. The combination is frequent, but largely unrecognized due to overlapping clinical manifestations. Patients presenting with both conditions seem to have an ominous course. Despite the overwhelming evidence supporting cardioselective beta-blockade safety and tolerability in COPD patients, beta-blockers are underprescribed to heart failure patients with concomitant COPD.

SUMMARY

COPD and heart failure coexistence is often overlooked. COPD diagnosis can remain unsuspected in heart failure patients due to similar symptoms. Although beta-blockers are well tolerated in COPD patients, they are overall less prescribed in this challenging population. COPD, at least at severe degrees of airflow obstruction, predicts a worse prognosis in heart failure patients.

The burden of chronic obstructive pulmonary disease in patients hospitalized with heart failure

OBJECTIVES

Like chronic heart failure, chronic obstructive pulmonary disease (COPD) is an enormous public health problem in industrialized countries. Our aim was to determine the prevalence and clinical impact of COPD among patients hospitalized for heart failure in a community hospital serving a population of 125,000 people.

METHODS

Between 2001 and 2003 a total of 638 patients (73 +/- 10 years, 48% men, 74% NYHA class III) were identified with a discharge diagnosis of heart failure. Medical charts were reviewed and vital status was obtained from a Central Population Registry.

RESULTS

COPD was diagnosed in 106 (17%) patients whose age was similar to those without COPD (73 +/- 9 vs. 73 +/- 11 years, P = 0.35). Patients with COPD were more often males (65% vs. 45%, P < 0.001). There were no differences in arterial hypertension, atrial fibrillation, diabetes mellitus and most laboratory markers except hemoglobin (141 +/- 20 vs. 132 +/- 20 g/l, P < 0.001) and uric acid (453 +/- 136 vs. 414 +/- 139 mmol/l, P = 0.013). At discharge, patients with COPD were less likely to receive beta-blockers (12% vs. 28%, odds ratio 0.35, 95% CI0.19-0.64). During follow-up, patients with COPD had higher mortality (73% vs. 60%, P = 0.016, hazard ratio 1.48, 95% CI 1.15-1.90). Kaplan-Meier (log-rank test, P = 0.002) and Cox proportional hazard analysis, adjusted for age, sex, hemoglobin, uric acid, and treatment with beta-blockers and furosemide (hazard ratio 1.38, 95% CI1.04-1.83, P = 0.024) demonstrated the prognostic importance of COPD.

CONCLUSIONS

COPD is frequent among hospitalized patients with heart failure. Beta-blockers are largely underused, which is probably a major reason for the higher mortality observed in patients with concomitant chronic heart failure and COPD.

Mortality after an Emergency Department Visit for Exacerbation of Chronic Obstructive Pulmonary Disease

OBJECTIVE

To describe the mortality after emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation.

DESIGN

Retrospective cohort study of ED patients with COPD exacerbation. Setting. Administrative data analysis.

PARTICIPANTS

Patients age 55 and over who visited the ED during a 2-year period with primary ICD-9 codes of 491, 492, or 496.

MEASUREMENTS

Demographic characteristics, comorbid conditions, hospital utilization for COPD, and vital status.

RESULTS

During the study period, there were 482 index visits with a median follow-up of 1,128 days (3.1 years). Demographic characteristics of the cohort were as follows: mean age 72 years, 56% female, 93% White, and 37% currently married. Mortality increased over time: 5% at 30 days, 9% at 60 days, 11% at 90 days, 16% at 180 days, 23% at 1 year, 32% at 2 years, and 39% at 3 years. At the end of follow-up, 220 (46%) patients had died. On multivariate analysis, independent predictors of mortality were increasing age (hazard ratio [HR] 1.3 per 5-year increase, 95% CI 1.2-1.4), having congestive heart failure (HR 1.6, 95% CI 1.2-2.1), having metastatic solid tumor (HR 3.3, 95% CI 2.0-5.5), and hospital utilization for COPD exacerbation during past year (HR 1.9, 95% CI 1.4-2.6).

CONCLUSION

The mortality rate after an ED visit for COPD exacerbation is quite high. Mortality is related to older age, specific comorbid conditions, and history of prior COPD exacerbations.

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Potential adverse effects of bronchodilators in the treatment of airways obstruction in older people: recommendations for prescribing

Asthma and chronic obstructive pulmonary disease (COPD) are common disorders that are associated with increasing morbidity and mortality in older people. Bronchodilators are used widely in patients with these conditions, but even when used in inhaled form can have systemic as well as local effects. Older people experience more adverse drug effects because of pharmacodynamic and pharmacokinetic changes and particularly drug-drug and drug-disease interactions. Cardiovascular disease is common in older people and beta-adrenoceptor agonists (beta-agonists) have inotropic and chronotropic effects that can increase arrhythmias and cardiomyopathy. They can also worsen or induce myocardial ischaemia and cause electrolyte disturbances that contribute to arrhythmias. Tremor is a well known distressing adverse effect of beta-agonist administration. Long-term beta-agonist use can be associated with tolerance, poor disease control, sudden life-threatening exacerbations and asthma-related deaths. Functional beta2-adrenoceptors are present in osteoblasts, and chronic use of beta-agonists has been implicated in osteoporosis. Inhaled anticholinergics are usually well tolerated but may cause dry mouth, which can be troublesome in older people. Pupillary dilatation, blurred vision and acute glaucoma can occur from escape of droplets from loosely fitting nebulizer masks. Although ECG changes have not been seen in randomized controlled trials of long-acting inhaled anticholinergics, supraventricular tachycardias have been observed in a 5-year randomized controlled trial of ipratropium bromide. Paradoxical bronchoconstriction can occur with inhaled anticholinergics as well as with beta-agonists, but tolerance has not been reported with anticholinergics. Anticholinergic drugs also cause central effects, most notably impairment of cognitive function, and these effects have been noted with inhaled agents. Use of theophylline is limited by its adverse effects, which range from commonly occurring gastrointestinal symptoms to palpitations, arrhythmias and reports of myocardial infarction. Seizures have been reported, but are rare. Theophylline is metabolized primarily by the liver, and commonly interacts with other medications. Its concentration in plasma should be monitored closely, especially in older people. Although many clinical trials have been conducted on bronchodilators in obstructive airways disease, the results of these clinical trials need to be interpreted with caution as older people are often under-represented and subjects with co-morbidities actively excluded from these trials.

Cardiac disease in chronic obstructive pulmonary disease

The cardiac manifestations of chronic obstructive pulmonary disease (COPD) are numerous. Impairments of right ventricular dysfunction and pulmonary vascular disease are well known to complicate the clinical course of COPD and correlate inversely with survival. The pathogenesis of pulmonary vascular disease in COPD is likely multifactorial and related to alterations in gas exchange and vascular biology, as well as structural changes of the pulmonary vasculature and mechanical factors. Several modalities currently exist for the assessment of pulmonary vascular disease in COPD, but right heart catheterization remains the gold standard. Although no specific therapy other than oxygen has been generally accepted for the treatment of pulmonary hypertension in this population, there has been renewed interest in specific pulmonary vasodilators. The coexistence of COPD and coronary artery disease occurs frequently. This association is likely related to shared risk factors as well as similar pathogenic mechanisms, such as systemic inflammation. Management strategies for the care of patients with COPD and coronary artery disease are similar to those without COPD, but care must be given to address their respiratory limitations. Arrhythmias occur frequently in patients with COPD, but are rarely fatal and can generally be treated medically. Use of beta-blockers in the management of cardiac disease, while a theoretical concern in patients with increased airway resistance, is generally safe with the use of cardioselective agents.

CHART: congestive cardiac failure in hospitals, an Australian review of treatment

Despite strong evidence supporting the use of angiotensin-converting enzyme inhibitors (ACED, beta-blockers, and spironolactone in heart failure, evidence suggests these drugs are under-used and under-dosed. The aim of the present study was to determine the impact of hospitalisation on heart failure pharmacotherapy in patients with congestive heart failure (CHF). A retrospective study was conducted, based on 300 consecutive admissions with the medical record diagnosis of heart failure, in each of seven grade one teaching hospitals. At admission, 49.5% of patients were treated with ACEI, 19.2% with beta-blockers and 8.1% with spironolactone. Twenty-six per cent of untreated patients started ACEI treatment during their hospital stay, and 9.4% started beta-blockers The main determinants of treatment with ACEI at discharge were a primary diagnosis of heart failure (odds ratio (OR) = 1.886) and the presence of a potential contraindication (high creatinine OR = 0.458, cough OR = 0.187, renal artery stenosis OR = 0.309). Patients were less likely to be discharged on beta-blockers if greater than 85 years of age (OR = 0.545), or there was mention of airways disease (OR = 0.347), asthma (OR = 0.238) or type 2 diabetes (OR = 0.721) on the medical record. Patients admitted by a cardiologist were more likely to be discharged on beta-blockers (OR = 3.207). Spironolactone was more likely used in patients with primary diagnosis of heart failure (OR = 1.549), aged less than 85 years (OR = 0.319), and/or admitted by a cardiologist (OR = 1.827). The substantial number of patients admitted to hospital with a secondary diagnosis of heart failure should be targeted for therapeutic optimisation.

Carvedilol in the treatment of elderly patients with chronic heart failure

Chronic heart failure (CHF) is common, and increases in incidence and prevalence with age. There are compelling data demonstrating reduced mortality and hospitalizations with adrenergic blockade in older patients with CHF. Despite this, many older patients remain under-treated. The aim of the present article is to review the potential mechanisms of the benefits of adrenergic blockade in CHF and the clinical data available from the large randomized studies, focusing particularly on older patients.

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.

Chronic obstructive pulmonary disease in heart failure. Prevalence, therapeutic and prognostic implications

BACKGROUND

Patients with heart failure (HF) frequently have comorbidities. Frequency, prognostic, and therapeutic implications of chronic obstructive pulmonary disease (COPD) in HF are largely unknown. We aimed to assess the prevalence and prognostic implications of COPD in a sample of stable patients with HF and to determine the frequency of beta-blocker (bB) use and rate of withdrawal according to COPD coexistence.

METHODS

We conducted a retrospective cohort study including 186 patients followed in an outpatient HF clinic. All patients had left ventricular systolic dysfunction and a spirometry result. Patients were classified according to the GOLD guidelines. Treatment was instituted at the discretion of the attending physicians. Prognosis was compared between groups using Cox proportional hazards regression. The primary end point was death or all-cause hospitalization.

RESULTS

The prevalence of COPD was 39.2% (73/186). No difference was detected between the COPD and non-COPD groups in the rate of bB use (86.3% vs 87.6%, P = .97) and withdrawal (11.1% and 8.1%, P = .71). Mean follow-up was 14.2 +/- 8.8 months. The primary end point occurred in 71 (38.2%) patients--32 in the COPD group and 39 in the remaining (43.8% and 34.5%, respectively; hazard ratio 1.40, 95% CI 0.88-2.24). Severe COPD (GOLD stages III and IV) was associated with an adverse outcome (hazard ratio 2.10, 95% CI 1.05-4.22).

CONCLUSIONS

We observed a high COPD prevalence in stable patients with HF. Severe COPD predicted worse prognosis. Rates of bB use were high and rates of bB withdrawal were low; both were independent of COPD.

Impact of chronic obstructive pulmonary disease on long-term outcome of patients hospitalized for heart failure

Chronic obstructive pulmonary disease (COPD) is a frequently neglected co-morbidity in patients with heart failure (HF). The aim of this study was to evaluate the prognostic impact of COPD in patients hospitalized for HF. Consecutive patients (n=799) admitted for a first episode of HF in all healthcare establishments of the Somme department (France) during 2000 were prospectively enrolled. Baseline characteristics and long-term prognosis were compared according to COPD status. COPD was diagnosed in 156 patients (19.5%). Compared with the no-COPD group, patients with COPD were predominantly men, more often smokers, and had lower discharge prescription rates of beta blockers (6% vs 27%, p<0.001). Five-year survival rate in patients with COPD was significantly lower than that of the no-COPD group (31% vs 42%, p=0.03). Compared with the expected survival of the age- and gender-matched general population, the 5-year survival rate in patients with COPD was dramatically lower (31% vs 71%). On multivariable analysis, COPD was a strong predictor of poorer outcome (hazard ratio 1.53, 95% confidence interval 1.21 to 1.94, p<0.001). COPD was an independent predictor of mortality in patients with preserved left ventricular ejection fraction and in patients with reduced ejection fraction. In conclusion, patients with HF and associated COPD have a poor prognosis with an impressive excess mortality compared to HF patients without COPD and the general population. Beta-blocker prescription rates remain deceptively low in this category of patients with HF.

Coexistent chronic obstructive pulmonary disease and heart failure in the elderly

The prevalence of chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) increases substantially with age. The coexistence of COPD and CHF is common but often unrecognized in elderly patients. To avoid overlooking COPD in elderly patients with known CHF pulmonary function tests should be routinely obtained. Likewise, to avoid overlooking CHF in elderly patients with known COPD left ventricular (LV) function should be routinely assessed. Plasma brain natriuretic peptide levels are useful to differentiate COPD exacerbation from CHF decompensation in patients presenting with acute dyspnea. Aging exacerbates skeletal muscle alterations that occur in patients with CHF and COPD. Skeletal muscle metabolic alterations and atrophy and the resulting deterioration of functional capacity progress rapidly in elderly patients with COPD and CHF. Physical conditioning reverses rapidly progressing skeletal muscle metabolic alterations and atrophy and promotes independence and life quality in the elderly. Physical conditioning is clearly an essential component of the management of elderly patients with COPD and CHF. The pharmacological management of patients with coexistent COPD and CHF should focus on not depriving these patients from long-term beta adrenergic blockade. Long-term beta adrenergic blockade has been repeatedly shown to improve survival in elderly patients with CHF due to LV systolic dysfunction and, contrary to conventional belief, is well tolerated by patients with COPD.

[Beta-blocker prescription and chronic obstructive pulmonary disease]

The beta-blocker (BB) prescription remains insufficient despite guidelines, especially, for chronic heart failure. Patients suffering chronic obstructive pulmonary disease (COPD) are particularly less treated by BB. The level of evidence for BB prescription is however especially high and as we will focus on, the level of evidence for the safety of BB in the COPD context is convincing enough. We, thus, propose to review the existing literature in regard to this prescription of BB in the chronic heart failure, in the coronary artery disease and for high blood pressure in COPD patients. We then propose our approach to improve the level of prescription of BB in COPD patient really justifying this prescription in cardiology.

Rates of hospitalizations and emergency department visits in patients with asthma and chronic obstructive pulmonary disease taking beta-blockers

STUDY OBJECTIVE

To determine the rates of hospitalizations and emergency department (ED) visits during cardioselective and nonselective beta-blocker therapy in patients with asthma and/or chronic obstructive pulmonary disease (COPD).

DESIGN

Retrospective, observational cohort study.

DATA SOURCE

Electronic medical records database.

PATIENTS

A total of 11,592 adult patients with asthma and/or COPD, identified from August 1, 1997-December 31, 2005, who were taking beta-blockers for at least 30 days or had never received a beta-blocker (controls).

MEASUREMENTS AND MAIN RESULTS

Of these patients, 3062 were taking cardioselective and 690 nonselective beta-blockers; 7840 were controls. The primary end point for the beta-blocker groups was the rate of hospitalizations and ED visits/patient-year of beta-blocker therapy relative to the control group. In patients with asthma with or without concomitant COPD, cardioselective beta-blockers were associated with a relative risk of 0.89 (95% confidence interval [CI] 0.53-1.50) for hospitalizations and 1.40 (95% CI 1.20-1.62) for ED visits compared with controls. Nonselective beta-blockers were associated with a relative risk of 2.47 (95% CI 1.37-4.48) for hospitalizations and 1.21 (95% CI 0.91-1.62) for ED visits. In patients with COPD only, cardioselective beta-blockers were associated with a relative risk of 0.64 (95% CI 0.43-0.96) for hospitalizations and 1.19 (95% CI 1.02-1.39) for ED visits. Nonselective beta-blockers were associated with a relative risk of 1.02 (95% CI 0.52-2.02) for hospitalizations and 0.51 (95% CI 0.33-0.80) for ED visits.

CONCLUSION

In patients with asthma with or without COPD, both cardioselective and nonselective beta-blocker use increased hospitalizations and ED visits compared with controls. Thus, these patients should receive beta-blocker therapy only if their cardiac risk exceeds their pulmonary risk and if they have concomitant cardiac disease for which beta-blockers decrease mortality, such as previous acute myocardial infarction or chronic heart failure. In patients with COPD only, cardioselective beta-blockers slightly increased the risk of ED visits but reduced the risk of hospitalizations. Nonselective beta-blocker therapy in these patients reduced the rate of ED visits and total visits. These findings suggest a larger safety margin with beta-blocker therapy in patients with COPD only than in those with asthma with or without COPD.