1
|
Matera MG, Rogliani P, Calzetta L, Cazzola M. An overview of the efficacy and safety of β 2-adrenoceptor antagonists for the treatment of chronic obstructive pulmonary disease. Expert Opin Drug Saf 2024; 23:833-844. [PMID: 38813912 DOI: 10.1080/14740338.2024.2362817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/29/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION The safety of β2-AR antagonists in the treatment of patients with COPD continues to be a topic of research and discussion within the medical community. Emerging evidence suggests potentially benefits in the management of this complex respiratory condition. However, antagonists that display a preference for β2-AR over β1-AR present a complex therapeutic challenge in COPD management, necessitating an understanding of differences in their pharmacological profiles and clinical implications. AREAS COVERED An overview of the mechanisms of action of β2-AR antagonists and their potential impact on respiratory function, their pharmacological interactions, clinical implications, and future perspectives in COPD. EXPERT OPINION β-Blockers have the potential to become a versatile class of therapeutic agents with benefits beyond their original cardiovascular use. However, the one-size-fits-all approach of prescribing β-blockers regardless of their receptor selectivity to COPD patients with concomitant heart disease may not be appropriate. Instead, it is advisable to develop an individualized treatment strategy based on a thorough assessment of the patient's overall health. The use of non selective β2-AR antagonists, functioning as inverse agonists at β2-ARs, has garnered interest and debate, but further research efforts should focus on elucidating the optimal use of β-AR antagonists in COPD, balancing cardiovascular benefits with potential respiratory risks to enhance outcomes and quality of life for individuals living with this debilitating respiratory condition.
Collapse
Affiliation(s)
- Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rogliani
- Unit of Respiratory Medicine, Department Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Unit of Respiratory Disease and Lung Function, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Mario Cazzola
- Unit of Respiratory Medicine, Department Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| |
Collapse
|
2
|
Devereux G, Cotton S, Nath M, McMeekin N, Campbell K, Chaudhuri R, Choudhury G, De Soyza A, Fielding S, Gompertz S, Haughney J, Lee AJ, MacLennan G, Morice A, Norrie J, Price D, Short P, Vestbo J, Walker P, Wedzicha J, Wilson A, Wu O, Lipworth BJ. Bisoprolol in Patients With Chronic Obstructive Pulmonary Disease at High Risk of Exacerbation: The BICS Randomized Clinical Trial. JAMA 2024:2819083. [PMID: 38762800 DOI: 10.1001/jama.2024.8771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2024]
Abstract
Importance Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Observational studies report that β-blocker use may be associated with reduced risk of COPD exacerbations. However, a recent trial reported that metoprolol did not reduce COPD exacerbations and increased COPD exacerbations requiring hospital admission. Objective To test whether bisoprolol decreased COPD exacerbations in people with COPD at high risk of exacerbations. Design, Setting, and Participants The Bisoprolol in COPD Study (BICS) was a double-blind placebo-controlled randomized clinical trial conducted in 76 UK sites (45 primary care clinics and 31 secondary clinics). Patients with COPD who had at least moderate airflow obstruction on spirometry (ratio of forced expiratory volume in the first second of expiration [FEV1] to forced vital capacity <0.7; FEV1 <80% predicted) and at least 2 COPD exacerbations treated with oral corticosteroids, antibiotics, or both in the prior 12 months were enrolled from October 17, 2018, to May 31, 2022. Follow-up concluded on April 18, 2023. Interventions Patients were randomly assigned to bisoprolol (n = 261) or placebo (n = 258). Bisoprolol was started at 1.25 mg orally daily and was titrated as tolerated during 4 sessions to a maximum dose of 5 mg/d, using a standardized protocol. Main Outcomes and Measures The primary clinical outcome was the number of patient-reported COPD exacerbations treated with oral corticosteroids, antibiotics, or both during the 1-year treatment period. Safety outcomes included serious adverse events and adverse reactions. Results Although the trial planned to enroll 1574 patients, recruitment was suspended from March 16, 2020, to July 31, 2021, due to the COVID-19 pandemic. Two patients in each group were excluded postrandomization. Among the 515 patients (mean [SD] age, 68 [7.9] years; 274 men [53%]; mean FEV1, 50.1%), primary outcome data were available for 514 patients (99.8%) and 371 (72.0%) continued taking the study drug. The primary outcome of patient-reported COPD exacerbations treated with oral corticosteroids, antibiotics, or both was 526 in the bisoprolol group, with a mean exacerbation rate of 2.03/y, vs 513 exacerbations in the placebo group, with a mean exacerbation rate of 2.01/y. The adjusted incidence rate ratio was 0.97 (95% CI, 0.84-1.13; P = .72). Serious adverse events occurred in 37 of 255 patients in the bisoprolol group (14.5%) vs 36 of 251 in the placebo group (14.3%; relative risk, 1.01; 95% CI, 0.62-1.66; P = .96). Conclusions and Relevance Among people with COPD at high risk of exacerbation, treatment with bisoprolol did not reduce the number of self-reported COPD exacerbations requiring treatment with oral corticosteroids, antibiotics, or both. Trial Registration isrctn.org Identifier: ISRCTN10497306.
Collapse
Affiliation(s)
- Graham Devereux
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, United Kingdom
- Liverpool University Hospitals Foundation NHS Trust, University Hospital Aintree, Liverpool, United Kingdom
| | - Seonaidh Cotton
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, United Kingdom
| | - Mintu Nath
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Nicola McMeekin
- School of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Karen Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, United Kingdom
| | - Rekha Chaudhuri
- School of Infection & Immunity, University of Glasgow, Glasgow, United Kingdom
| | | | - Anthony De Soyza
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shona Fielding
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Simon Gompertz
- Department of Respiratory Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - John Haughney
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
| | - Amanda J Lee
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, United Kingdom
| | - Alyn Morice
- Cardiovascular and Respiratory Studies, Castle Hill Hospital, Hull, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh BioQuarter, Edinburgh, United Kingdom
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
| | - Philip Short
- Respiratory Medicine, Ninewells Hospital, Dundee, United Kingdom
| | - Jorgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Paul Walker
- Liverpool University Hospitals Foundation NHS Trust, University Hospital Aintree, Liverpool, United Kingdom
| | - Jadwiga Wedzicha
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Andrew Wilson
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Olivia Wu
- School of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Brian J Lipworth
- Ninewells Hospital and Medical School, University of Dundee, Dundee, United Kingdom
| |
Collapse
|
3
|
LaFon DC, Helgeson ES, Lindberg S, Voelker H, Bhatt SP, Casaburi R, Cassady SJ, Connett J, Criner GJ, Hatipoglu U, Kaminsky DA, Kunisaki KM, Lazarus SC, McEvoy CE, Reed RM, Sciurba FC, Stringer W, Dransfield MT. β-Blocker Use and Clinical Outcomes in Patients With COPD Following Acute Myocardial Infarction. JAMA Netw Open 2024; 7:e247535. [PMID: 38771577 PMCID: PMC11109775 DOI: 10.1001/jamanetworkopen.2024.7535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 02/21/2024] [Indexed: 05/22/2024] Open
Abstract
Importance While β-blockers are associated with decreased mortality in cardiovascular disease (CVD), exacerbation-prone patients with chronic obstructive pulmonary disease (COPD) who received metoprolol in the Beta-Blockers for the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease (BLOCK-COPD) trial experienced increased risk of exacerbations requiring hospitalization. However, the study excluded individuals with established indications for the drug, raising questions about the overall risk and benefit in patients with COPD following acute myocardial infarction (AMI). Objective To investigate whether β-blocker prescription at hospital discharge is associated with increased risk of mortality or adverse cardiopulmonary outcomes in patients with COPD and AMI. Design, Setting, and Participants This prospective, longitudinal cohort study with 6 months of follow-up enrolled patients aged 35 years or older with COPD who underwent cardiac catheterization for AMI at 18 BLOCK-COPD network hospitals in the US from June 2020 through May 2022. Exposure Prescription for any β-blocker at hospital discharge. Main Outcomes and Measures The primary outcome was time to the composite outcome of death or all-cause hospitalization or revascularization. Secondary outcomes included death, hospitalization, or revascularization for CVD events, death or hospitalization for COPD or respiratory events, and treatment for COPD exacerbations. Results Among 3531 patients who underwent cardiac catheterization for AMI, prevalence of COPD was 17.1% (95% CI, 15.8%-18.4%). Of 579 total patients with COPD and AMI, 502 (86.7%) were prescribed a β-blocker at discharge. Among the 562 patients with COPD included in the final analysis, median age was 70.0 years (range, 38.0-94.0 years) and 329 (58.5%) were male; 553 of the 579 patients (95.5%) had follow-up information. Among those discharged with β-blockers, there was no increased risk of the primary end point of all-cause mortality, revascularization, or hospitalization (hazard ratio [HR], 1.01; 95% CI, 0.66-1.54; P = .96) or of cardiovascular events (HR, 1.11; 95% CI, 0.65-1.92; P = .69), COPD-related or respiratory events (HR, 0.75; 95% CI, 0.34-1.66; P = .48), or treatment for COPD exacerbations (rate ratio, 1.01; 95% CI, 0.53-1.91; P = .98). Conclusions and Relevance In this cohort study, β-blocker prescription at hospital discharge was not associated with increased risk of adverse outcomes in patients with COPD and AMI. These findings support use of β-blockers in patients with COPD and recent AMI.
Collapse
Affiliation(s)
- David C. LaFon
- Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, The University of Alabama at Birmingham
- UAB Lung Health Center, Heersink School of Medicine, The University of Alabama at Birmingham
| | - Erika S. Helgeson
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis
| | - Sarah Lindberg
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis
| | - Helen Voelker
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis
| | - Surya P. Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, The University of Alabama at Birmingham
- UAB Lung Health Center, Heersink School of Medicine, The University of Alabama at Birmingham
| | - Richard Casaburi
- Lundquist Institute for Biomedical Innovation, Harbor–UCLA Medical Center, Torrance, California
| | - Steven J. Cassady
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore
| | - John Connett
- Division of Biostatistics and Health Data Science, University of Minnesota, Minneapolis
| | - Gerard J. Criner
- Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Umur Hatipoglu
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - David A. Kaminsky
- Pulmonary and Critical Care Medicine, University of Vermont, Burlington
| | | | - Stephen C. Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco
- Cardiovascular Research Institute, University of California San Francisco
| | | | - Robert M. Reed
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore
| | - Frank C. Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William Stringer
- Lundquist Institute for Biomedical Innovation, Harbor–UCLA Medical Center, Torrance, California
| | - Mark T. Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, Heersink School of Medicine, The University of Alabama at Birmingham
- UAB Lung Health Center, Heersink School of Medicine, The University of Alabama at Birmingham
- Birmingham VA Medical Center, Birmingham, Alabama
| |
Collapse
|
4
|
de Miguel-Díez J, Núñez Villota J, Santos Pérez S, Manito Lorite N, Alcázar Navarrete B, Delgado Jiménez JF, Soler-Cataluña JJ, Pascual Figal D, Sobradillo Ecenarro P, Gómez Doblas JJ. Multidisciplinary Management of Patients With Chronic Obstructive Pulmonary Disease and Cardiovascular Disease. Arch Bronconeumol 2024; 60:226-237. [PMID: 38383272 DOI: 10.1016/j.arbres.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/23/2024]
Abstract
Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently coexist, increasing the prevalence of both entities and impacting on symptoms and prognosis. CVD should be suspected in patients with COPD who have high/very high risk scores on validated scales, frequent exacerbations, precordial pain, disproportionate dyspnea, or palpitations. They should be referred to cardiology if they have palpitations of unknown cause or angina pain. COPD should be suspected in patients with CVD if they have recurrent bronchitis, cough and expectoration, or disproportionate dyspnea. They should be referred to a pulmonologist if they have rhonchi or wheezing, air trapping, emphysema, or signs of chronic bronchitis. Treatment of COPD in cardiovascular patients should include long-acting muscarinic receptor antagonists (LAMA) or long-acting beta-agonists (LABA) in low-risk or high-risk non-exacerbators, and LAMA/LABA/inhaled corticosteroids in exacerbators who are not controlled with bronchodilators. Cardioselective beta-blockers should be favored in patients with CVD, the long-term need for amiodarone should be assessed, and antiplatelet drugs should be maintained if indicated.
Collapse
Affiliation(s)
- Javier de Miguel-Díez
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, Madrid, Spain.
| | - Julio Núñez Villota
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Salud Santos Pérez
- Servicio de Neumología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Nicolás Manito Lorite
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Juan Francisco Delgado Jiménez
- Servicio de Cardiología e Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Medicina, UCM, CIBERCV, Madrid, Spain
| | - Juan José Soler-Cataluña
- Servicio de Neumología, Hospital Arnau de Vilanova-Lliria, Valencia, Spain; Departamento de Medicina, Universitat de València, Valencia, Spain
| | - Domingo Pascual Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | | |
Collapse
|
5
|
Hua JL, Yang ZF, Cheng QJ, Han YP, Li ZT, Dai RR, He BF, Wu YX, Zhang J. Prevention of exacerbation in patients with moderate-to-very severe COPD with the intent to modulate respiratory microbiome: a pilot prospective, multi-center, randomized controlled trial. Front Med (Lausanne) 2024; 10:1265544. [PMID: 38249987 PMCID: PMC10797043 DOI: 10.3389/fmed.2023.1265544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Considering the role of bacteria in the onset of acute exacerbation of COPD (AECOPD), we hypothesized that the use of influenza-Streptococcus pneumoniae vaccination, oral probiotics or inhaled amikacin could prevent AECOPD. Methods In this pilot prospective, muti-central, randomized trial, moderate-to-very severe COPD subjects with a history of moderate-to-severe exacerbations in the previous year were enrolled and assigned in a ratio of 1:1:1:1 into 4 groups. All participants were managed based on the conventional treatment recommended by GOLD 2019 report for 3 months, with three groups receiving additional treatment of inhaled amikacin (0.4 g twice daily, 5-7 days monthly for 3 months), oral probiotic Lactobacillus rhamnosus GG (1 tablet daily for 3 months), or influenza-S. pneumoniae vaccination. The primary endpoint was time to the next onset of moderate-to-severe AECOPD from enrollment. Secondary endpoints included CAT score, mMRC score, adverse events, and survival in 12 months. Results Among all 112 analyzed subjects (101 males, 96 smokers or ex-smokers, mean ± SD age 67.19 ± 7.39 years, FEV1 41.06 ± 16.09% predicted), those who were given dual vaccination (239.7 vs. 198.2 days, p = 0.044, 95%CI [0.85, 82.13]) and oral probiotics (248.8 vs. 198.2 days, p = 0.017, 95%CI [7.49, 93.59]) had significantly delayed onset of next moderate-to-severe AECOPD than those received conventional treatment only. For subjects with high symptom burden, the exacerbations were significantly delayed in inhaled amikacin group as compared to the conventional treatment group (237.3 vs. 179.1 days, p = 0.009, 95%CI [12.40,104.04]). The three interventions seemed to be safe and well tolerated for patient with stable COPD. Conclusion The influenza-S. pneumoniae vaccine and long-term oral probiotic LGG can significantly delay the next moderate-to-severe AECOPD. Periodically amikacin inhalation seems to work in symptomatic patients. The findings in the current study warrants validation in future studies with microbiome investigation.Clinical trial registration:https://clinicaltrials.gov/, identifier NCT03449459.
Collapse
Affiliation(s)
- Jian-lan Hua
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zi-feng Yang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Qi-jian Cheng
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yao-pin Han
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zheng-tu Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Ran-ran Dai
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bin-feng He
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi-xing Wu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jing Zhang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Lung Inflammation and Injury, Shanghai, China
| |
Collapse
|
6
|
Ray S, Nair T, Sawhney J, Erwinanto, Rosman A, Reyes E, Go L, Sukonthasarn A, Ariyachaipanich A, Hung PM, Chaudhari H, Malhi HS. Role of β-blockers in the cardiovascular disease continuum: a collaborative Delphi survey-based consensus from Asia-Pacific. Curr Med Res Opin 2023; 39:1671-1683. [PMID: 37694536 DOI: 10.1080/03007995.2023.2256218] [Citation(s) in RCA: 1] [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] [Received: 04/27/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE This Delphi method of consensus was designed to develop scientific statements for β-blockers in the continuum of cardiovascular diseases with a special focus on the role of bisoprolol. METHODS Eleven experienced cardiologists from across the Asia-Pacific countries participated in two rounds of the survey. In the first round, experts were asked to rate agreement/disagreement with 35 statements across seven domains regarding the use of β-blockers for treating hypertension, heart failure, coronary artery diseases, co-morbidities, as well as their safety profile, usage pattern, and pharmacokinetic variability. A consensus for a statement could be reached with >70% agreement. RESULTS Except for seven statements, all attained consensus in the first round. In the second round that was conducted virtually, the experts re-appraised their ratings for the seven statements along with a critical appraisal of two additional statements that were suggested by experts in the preceding round. At the end of the second round, the final version included 36 statements (34 original statements, two statements suggested by experts, and the omission of one statement that did not attain consensus). The final version of statements in the second round was disseminated among experts for their approval followed by manuscript development. CONCLUSION Attainment of consensus for almost all statements reconfirms the clinical benefits of β-blockers, particularly β1-selective blockers for the entire spectrum of cardiovascular diseases.
Collapse
Affiliation(s)
- Saumitra Ray
- Department of Cardiology, AMRI Hospital (S), West Bengal, Kolkata, India
| | - Tiny Nair
- Department of Cardiology, PRS Hospital, Trivandrum, Kerala, India
| | - Jps Sawhney
- Department of Cardiology, Member Board of Management at Sir Ganga Ram Hospital, New Delhi, India
| | - Erwinanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjajaran University, Jawa Barat, Indonesia
| | | | - Eugene Reyes
- Section of Cardiology, Department of Internal Medicine, UP-Philippine General Hospital, Manila, Philippines
| | - Loewe Go
- Internal Medicine - Cardiology, St. Luke's Medical Center, Taguig, Philippines
| | | | - Aekarach Ariyachaipanich
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Phạm Manh Hung
- National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
| | - Harshal Chaudhari
- Merck Specialities Pvt. Ltd., India, an affiliate of Merck KGaA, Darmstadt, Germany
| | | |
Collapse
|
7
|
Khan KS, Jawaid S, Memon UA, Perera T, Khan U, Farwa UE, Jindal U, Afzal MS, Razzaq W, Abdin ZU, Khawaja UA. Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions. Cureus 2023; 15:e43694. [PMID: 37724212 PMCID: PMC10505355 DOI: 10.7759/cureus.43694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.
Collapse
Affiliation(s)
- Khizar S Khan
- Basic Sciences, Foundation University Medical College, Islamabad, PAK
| | - Sanyah Jawaid
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Unaib Ahmed Memon
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | - Tharindu Perera
- General Medicine, Grodno State Medical University, Grodno, BLR
| | - Usman Khan
- General Practice, Akhtar Saeed Medical and Dental College, Lahore, PAK
| | - Umm E Farwa
- Emergency Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Urmi Jindal
- Internal Medicine, KJ Somaiya Medical College, Mumbai, IND
| | | | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Clinical and Translational Research, Dr Ferrer BioPharma, South Miami, USA
| |
Collapse
|
8
|
Khan O, Patel M, Tomdio AN, Beall J, Jovin IS. Beta-Blockers in the Prevention and Treatment of Ischemic Heart Disease: Evidence and Clinical Practice. Heart Views 2023; 24:41-49. [PMID: 37124437 PMCID: PMC10144413 DOI: 10.4103/heartviews.heartviews_75_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/02/2022] [Indexed: 02/25/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Omer Khan
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Murti Patel
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anna N. Tomdio
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jeffrey Beall
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Ion S. Jovin
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| |
Collapse
|
9
|
Editorial commentary: Which COPD patients benefit from beta-blocker therapy? Trends Cardiovasc Med 2023; 33:62-63. [PMID: 34929302 DOI: 10.1016/j.tcm.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 02/01/2023]
|
10
|
Ruzieh M, Baugh AD, Al Jebbawi L, Edwards ES, Jia KQ, Dransfield MT, Foy AJ. Beta-blocker use in patients with chronic obstructive pulmonary disease: A systematic review: A systematic review of βB in COPD. Trends Cardiovasc Med 2023; 33:53-61. [PMID: 34856338 DOI: 10.1016/j.tcm.2021.11.004] [Citation(s) in RCA: 1] [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] [Received: 09/23/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 02/01/2023]
Abstract
Beta-blockers (βB) are a frequently used class of medications. Although βB have many indications, those related to cardiovascular disease are among the most common and important. However, in patients with chronic obstructive pulmonary disease (COPD), βB are used less often due to concerns about an unfavorable impact on respiratory morbidity and mortality. We performed a systematic review to assess the safety of βB in patients with COPD. We included a total of 2 randomized controlled trials and 28 observational studies. The majority found statistically significant reductions in mortality. The two higher quality observational studies reported increased mortality with βB. The risk of COPD exacerbations was reduced in about half of the studies. Nonetheless, there were significant biases that confounded the results. The highest quality RCT found a significant increase in severe and very severe COPD exacerbations with βB use. In conclusion, data on the safety of βB in patients with COPD are conflicting. However, given higher quality evidence showed harm with their use, βB should be prescribed with caution in patients with COPD, including patients with cardiac indication for βB.
Collapse
Affiliation(s)
- Mohammed Ruzieh
- Division of Cardiovascular Medicine. University of Florida, Gainesville, FL.
| | - Aaron D Baugh
- Pulmonary, Critical Care, Allergy, and Sleep Medicine. University of California San Francisco, San Francisco, CA
| | - Lama Al Jebbawi
- Department of Internal Medicine. Henry Ford Allegiance Health Affiliation, Jackson, MI
| | - Emily S Edwards
- Department of Internal Medicine. University of Florida, Gainesville, FL
| | - Kelly Qi Jia
- Penn State Heart and Vascular Institute. Penn State College of Medicine, Hershey, PA
| | - Mark T Dransfield
- Pulmonary, Allergy, and Critical Care Medicine. University of Alabama at Birmingham, Birmingham, AL
| | - Andrew J Foy
- Penn State Heart and Vascular Institute. Penn State College of Medicine, Hershey, PA
| |
Collapse
|
11
|
Parekh TM, Helgeson ES, Connett J, Voelker H, Ling SX, Lazarus SC, Bhatt SP, MacDonald DM, Mkorombindo T, Kunisaki KM, Fortis S, Kaminsky D, Dransfield MT. Lung Function and the Risk of Exacerbation in the β-Blockers for the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease Trial. Ann Am Thorac Soc 2022; 19:1642-1649. [PMID: 35363600 PMCID: PMC9528740 DOI: 10.1513/annalsats.202109-1042oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/01/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: The BLOCK COPD (β-Blockers for the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease) study found that metoprolol was associated with a higher risk of severe exacerbation. Objectives: To determine the mechanism underlying these results, we compared changes in lung function over the course of the study between treatment groups and evaluated whether baseline bronchodilator response or early reduction in forced expiratory volume in 1 second (FEV1) or forced vital capacity (FVC) was associated with exacerbation risk. Methods: We compared changes in lung function (FEV1 and FVC) over the treatment period between treatment groups using linear mixed-effect models. Cox proportional hazards models were used to evaluate the association between baseline bronchodilator responsiveness (FEV1, FVC, and combined FEV1 and FVC), early post-randomization (14 d) change in lung function, and the interaction between treatment assignment and these measures with risk of any or severe or very severe exacerbations. Negative binomial models were used to evaluate the relationship between bronchodilator responsiveness, the interaction between bronchodilator responsiveness and treatment assignment, and exacerbation rate. Results: Over the 336-day treatment period, individuals in the metoprolol group had a significantly greater decrease in logarithmic FEV1 from baseline to visit on Day 28 than individuals in the placebo group. Individuals in the metoprolol group had a significantly greater decrease in FVC from baseline to visits on Days 14 and 28, and also a significantly greater decrease in logarithmic FVC from baseline to visits on Days 42 and 112 than individuals in the placebo group. There were no associations between early lung function reduction or interactions between lung function reduction and treatment assignment and time to any or severe or very severe exacerbations. There were no interactions between treatment arm and baseline bronchodilator responsiveness measures on risk or rate of exacerbations. However, those with baseline FVC bronchodilator responsiveness had a higher rate of severe or very severe exacerbations (adjusted rate ratio, 1.62; 95% confidence interval, 1.04-2.48). Conclusions: Metoprolol was associated with reduced lung function during the early part of the treatment period, but these effects were modest and did not persist. Early lung function reduction and baseline bronchodilator responsiveness did not interact with the treatment arm to predict exacerbations; however, baseline FVC bronchodilator responsiveness was associated with a 60% higher rate of severe or very severe exacerbations. Clinical trial registered with www.clinicaltrials.gov (NCT02587351).
Collapse
Affiliation(s)
| | - Erika S. Helgeson
- University of Minnesota Academic Health Center, Minneapolis, Minnesota
| | | | | | | | | | - Surya P. Bhatt
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Ken M. Kunisaki
- University of Minnesota, Minneapolis, Minnesota
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Spyridon Fortis
- University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - David Kaminsky
- University of Vermont College of Medicine, Burlington, Vermont
| | | |
Collapse
|
12
|
Kowalczys A, Bohdan M, Wilkowska A, Pawłowska I, Pawłowski L, Janowiak P, Jassem E, Lelonek M, Gruchała M, Sobański P. Comprehensive care for people living with heart failure and chronic obstructive pulmonary disease—Integration of palliative care with disease-specific care: From guidelines to practice. Front Cardiovasc Med 2022; 9:895495. [PMID: 36237915 PMCID: PMC9551106 DOI: 10.3389/fcvm.2022.895495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are the leading global epidemiological, clinical, social, and economic burden. Due to similar risk factors and overlapping pathophysiological pathways, the coexistence of these two diseases is common. People with severe COPD and advanced chronic HF (CHF) develop similar symptoms that aggravate if evoking mechanisms overlap. The coexistence of COPD and CHF limits the quality of life (QoL) and worsens symptom burden and mortality, more than if only one of them is present. Both conditions progress despite optimal, guidelines directed treatment, frequently exacerbate, and have a similar or worse prognosis in comparison with many malignant diseases. Palliative care (PC) is effective in QoL improvement of people with CHF and COPD and may be a valuable addition to standard treatment. The current guidelines for the management of HF and COPD emphasize the importance of early integration of PC parallel to disease-modifying therapies in people with advanced forms of both conditions. The number of patients with HF and COPD requiring PC is high and will grow in future decades necessitating further attention to research and knowledge translation in this field of practice. Care pathways for people living with concomitant HF and COPD have not been published so far. It can be hypothesized that overlapping of symptoms and similarity in disease trajectories allow to draw a model of care which will address symptoms and problems caused by either condition.
Collapse
Affiliation(s)
- Anna Kowalczys
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
- *Correspondence: Anna Kowalczys,
| | - Michał Bohdan
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Alina Wilkowska
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Iga Pawłowska
- Department of Pharmacology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Leszek Pawłowski
- Department of Palliative Medicine, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Piotr Janowiak
- Department of Pneumonology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Ewa Jassem
- Department of Pneumonology, Medical University of Gdańsk, Gdańsk, Pomeranian, Poland
| | - Małgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Łódź, Poland
| | - Marcin Gruchała
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Piotr Sobański
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Schwyz Hospital, Schwyz, Switzerland
| |
Collapse
|
13
|
Balbirsingh V, Mohammed AS, Turner AM, Newnham M. Cardiovascular disease in chronic obstructive pulmonary disease: a narrative review. Thorax 2022; 77:thoraxjnl-2021-218333. [PMID: 35772939 DOI: 10.1136/thoraxjnl-2021-218333] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 06/06/2022] [Indexed: 11/04/2022]
Abstract
Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease (CVD) and concomitant disease leads to reduced quality of life, increased hospitalisations and worse survival. Acute pulmonary exacerbations are an important contributor to COPD burden and are associated with increased cardiovascular (CV) events. Both COPD and CVD represent a significant global disease impact and understanding the relationship between the two could potentially reduce this burden. The association between CVD and COPD could be a consequence of (1) shared risk factors (environmental and/or genetic) (2) shared pathophysiological pathways (3) coassociation from a high prevalence of both diseases (4) adverse effects (including pulmonary exacerbations) of COPD contributing to CVD and (5) CVD medications potentially worsening COPD and vice versa. CV risk in COPD has traditionally been associated with increasing disease severity, but there are other relevant COPD subtype associations including radiological subtypes, those with frequent pulmonary exacerbations and novel disease clusters. While the prevalence of CVD is high in COPD populations, it may be underdiagnosed, and improved risk prediction, diagnosis and treatment optimisation could lead to improved outcomes. This state-of-the-art review will explore the incidence/prevalence, COPD subtype associations, shared pathophysiology and genetics, risk prediction, and treatment of CVD in COPD.
Collapse
Affiliation(s)
- Vishanna Balbirsingh
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrea S Mohammed
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Michael Newnham
- Institute of Applied Health Research, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| |
Collapse
|
14
|
Arcoraci V, Squadrito F, Rottura M, Barbieri MA, Pallio G, Irrera N, Nobili A, Natoli G, Argano C, Squadrito G, Corrao S. Beta-Blocker Use in Older Hospitalized Patients Affected by Heart Failure and Chronic Obstructive Pulmonary Disease: An Italian Survey From the REPOSI Register. Front Cardiovasc Med 2022; 9:876693. [PMID: 35651906 PMCID: PMC9149000 DOI: 10.3389/fcvm.2022.876693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/05/2022] [Indexed: 11/30/2022] Open
Abstract
Beta (β)-blockers (BB) are useful in reducing morbidity and mortality in patients with heart failure (HF) and concomitant chronic obstructive pulmonary disease (COPD). Nevertheless, the use of BBs could induce bronchoconstriction due to β2-blockade. For this reason, both the ESC and GOLD guidelines strongly suggest the use of selective β1-BB in patients with HF and COPD. However, low adherence to guidelines was observed in multiple clinical settings. The aim of the study was to investigate the BBs use in older patients affected by HF and COPD, recorded in the REPOSI register. Of 942 patients affected by HF, 47.1% were treated with BBs. The use of BBs was significantly lower in patients with HF and COPD than in patients affected by HF alone, both at admission and at discharge (admission, 36.9% vs. 51.3%; discharge, 38.0% vs. 51.7%). In addition, no further BB users were found at discharge. The probability to being treated with a BB was significantly lower in patients with HF also affected by COPD (adj. OR, 95% CI: 0.50, 0.37–0.67), while the diagnosis of COPD was not associated with the choice of selective β1-BB (adj. OR, 95% CI: 1.33, 0.76–2.34). Despite clear recommendations by clinical guidelines, a significant underuse of BBs was also observed after hospital discharge. In COPD affected patients, physicians unreasonably reject BBs use, rather than choosing a β1-BB. The expected improvement of the BB prescriptions after hospitalization was not observed. A multidisciplinary approach among hospital physicians, general practitioners, and pharmacologists should be carried out for better drug management and adherence to guideline recommendations.
Collapse
Affiliation(s)
- Vincenzo Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- *Correspondence: Vincenzo Arcoraci
| | - Francesco Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- SunNutraPharma, Academic Spin-Off Company of the University of Messina, Messina, Italy
| | - Michelangelo Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | - Giovanni Pallio
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Alessandro Nobili
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Giuseppe Natoli
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D'Alessandro”, PROMISE, University of Palermo, Palermo, Italy
| | - Christiano Argano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D'Alessandro”, PROMISE, University of Palermo, Palermo, Italy
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Salvatore Corrao
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties “G. D'Alessandro”, PROMISE, University of Palermo, Palermo, Italy
- Department of Internal Medicine, National Relevance and High Specialization Hospital Trust ARNAS Civico, Palermo, Italy
| |
Collapse
|
15
|
|
16
|
Cotton S, Devereux G, Abbas H, Briggs A, Campbell K, Chaudhuri R, Choudhury G, Dawson D, De Soyza A, Fielding S, Gompertz S, Haughney J, Lang CC, Lee AJ, MacLennan G, MacNee W, McCormack K, McMeekin N, Mills NL, Morice A, Norrie J, Petrie MC, Price D, Short P, Vestbo J, Walker P, Wedzicha J, Wilson A, Lipworth BJ. Use of the oral beta blocker bisoprolol to reduce the rate of exacerbation in people with chronic obstructive pulmonary disease (COPD): a randomised controlled trial (BICS). Trials 2022; 23:307. [PMID: 35422024 PMCID: PMC9009490 DOI: 10.1186/s13063-022-06226-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/26/2022] [Indexed: 12/13/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is associated with significant morbidity, mortality and healthcare costs. Beta blockers are well-established drugs widely used to treat cardiovascular conditions. Observational studies consistently report that beta blocker use in people with COPD is associated with a reduced risk of COPD exacerbations. The bisoprolol in COPD study (BICS) investigates whether adding bisoprolol to routine COPD treatment has clinical and cost-effective benefits. A sub-study will risk stratify participants for heart failure to investigate whether any beneficial effect of bisoprolol is restricted to those with unrecognised heart disease. Methods BICS is a pragmatic randomised parallel group double-blind placebo-controlled trial conducted in UK primary and secondary care sites. The major inclusion criteria are an established predominant respiratory diagnosis of COPD (post-bronchodilator FEV1 < 80% predicted, FEV1/FVC < 0.7), a self-reported history of ≥ 2 exacerbations requiring treatment with antibiotics and/or oral corticosteroids in a 12-month period since March 2019, age ≥ 40 years and a smoking history ≥ 10 pack years. A computerised randomisation system will allocate 1574 participants with equal probability to intervention or control groups, stratified by centre and recruitment in primary/secondary care. The intervention is bisoprolol (1.25 mg tablets) or identical placebo. The dose of bisoprolol/placebo is titrated up to a maximum of 4 tablets a day (5 mg bisoprolol) over 4–7 weeks depending on tolerance to up-dosing of bisoprolol/placebo—these titration assessments are completed by telephone or video call. Participants complete the remainder of the 52-week treatment period on the final titrated dose (1, 2, 3, 4 tablets) and during that time are followed up at 26 and 52 weeks by telephone or video call. The primary outcome is the total number of participant reported COPD exacerbations requiring oral corticosteroids and/or antibiotics during the 52-week treatment period. A sub-study will risk stratify participants for heart failure by echocardiography and measurement of blood biomarkers. Discussion The demonstration that bisoprolol reduces the incidence of exacerbations would be relevant not only to patients and clinicians but also to healthcare providers, in the UK and globally. Trial registration Current controlled trials ISRCTN10497306. Registered on 16 August 2018 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06226-8.
Collapse
Affiliation(s)
- Seonaidh Cotton
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Graham Devereux
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK. .,Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
| | - Hassan Abbas
- Division of Applied Medicine, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Andrew Briggs
- Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Karen Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Rekha Chaudhuri
- Gartnavel General Hospital, University of Glasgow, Glasgow, G12 0YN, UK
| | | | - Dana Dawson
- Division of Applied Medicine, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Anthony De Soyza
- University of Newcastle, Medical School, Newcastle Upon Tyne, NE2 4HH, UK
| | - Shona Fielding
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Simon Gompertz
- Queen Elizabeth Hospital Birmingham, Birmingham, B15 2WB, UK
| | - John Haughney
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Chim C Lang
- Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
| | - Amanda J Lee
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - William MacNee
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Kirsty McCormack
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Nicola McMeekin
- Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Alyn Morice
- Cardiovascular and Respiratory Studies, Castle Hill Hospital, Hull, HU16 5JQ, UK
| | - John Norrie
- NINE Edinburgh BioQuarter, University of Edinburgh, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - Mark C Petrie
- Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TD, UK
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | | | - Jorgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, M23 9LT, UK
| | - Paul Walker
- Liverpool University Hospitals Foundation NHS Trust, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL, UK
| | - Jadwiga Wedzicha
- National Heart and Lung Institute, Imperial College, London, SW3 6LY, UK
| | - Andrew Wilson
- Department of Medicine, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Brian J Lipworth
- Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
| |
Collapse
|
17
|
Priel E, Wahab M, Mondal T, Freitag A, O'Byrne PM, Killian KJ, Satia I. The Impact of beta blockade on the cardio-respiratory system and symptoms during exercise. Curr Res Physiol 2022; 4:235-242. [PMID: 34988470 PMCID: PMC8710988 DOI: 10.1016/j.crphys.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 09/22/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background Beta blockers prolong life in patients with cardiovascular diseases. Negative chronotropic and inotropic effects carry the potential to adversely effect peripheral skeletal and airway smooth muscle contributing to further fatigue, dyspnea and exercise intolerance. Research questions Do beta-blockers reduce maximal power output (MPO), VO2 max, cardiorespiratory responses, increase the perceived effort required to cycle and breath during cardiopulmonary exercise tests (CPET) and limit the capacity to exercise? Methods Retrospective observational study of subjects performing CPET to capacity from 1988 to 2012. Subjects with and without beta-blockers were compared: baseline physiological characteristics, MPO, VO2 max, heart rate max, ventilation responses and perceived exertion required to cycle and breathe (modified Borg scale). Forward stepwise linear additive regression was performed with MPO as the dependent factor with height, age, gender, muscle strength, FEV1 and DLCO as independent contributors. Results 42,771 subjects were included 7,787 were receiving beta-blocker [mean age 61 yrs, BMI 28.40 kg/m2, 9% airflow obstruction (FEV1/FVC<0.7)] and 34,984 were not [mean age 51yrs, BMI 27.40 kg/m2, 11% airflow obstruction]. Heart rate was lower by 18.2% (95% C.I. 18.15–18.38) (p<0.0001) while Oxygen pulse (VO2/HR) was higher by 19.5% (95% C.I. 19.3–19.7) in those receiving beta blockers. Maximum power output (MPO) was 3.3% lower in those taking beta-blockers. The perceived effort required to cycle and breathe (mBorg) was 8% lower in those taking beta-blockers. Interpretation Increases in oxygen pulse minimize the reduction in exercise intolerance and symptom handicap associated with beta-blockers. Comprehensive set of exercise physiology measurements in a large cohort, to delineate any hazardous effects of beta blockade. Beta-blockers attenuate the heart rate at rest and during exercise. Beta-blockade has no meaningful effects on muscle strength, breathing capacity or exercise induced bronchoconstriction. Beta Blockers were not associated with a reduction in Maximal power output. Increases in Oxygen pulse minimize the reduction in exercise intolerance and symptom handicap associated with beta-blockers.
Collapse
Affiliation(s)
- Eldar Priel
- McMaster University Department of Medicine, Hamilton, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
| | - Mustafaa Wahab
- McMaster University Department of Medicine, Hamilton, Canada
| | - Tapas Mondal
- McMaster University Department of Medicine, Hamilton, Canada
| | - Andy Freitag
- McMaster University Department of Medicine, Hamilton, Canada
| | - Paul M O'Byrne
- McMaster University Department of Medicine, Hamilton, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
| | | | - Imran Satia
- McMaster University Department of Medicine, Hamilton, Canada.,Firestone Institute for Respiratory Health, St Joseph's Healthcare, Hamilton, Canada
| |
Collapse
|
18
|
Ciccarelli M, Dawson D, Falcao-Pires I, Giacca M, Hamdani N, Heymans S, Hooghiemstra A, Leeuwis A, Hermkens D, Tocchetti CG, van der Velden J, Zacchigna S, Thum T. Reciprocal organ interactions during heart failure: a position paper from the ESC Working Group on Myocardial Function. Cardiovasc Res 2021; 117:2416-2433. [PMID: 33483724 PMCID: PMC8562335 DOI: 10.1093/cvr/cvab009] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/20/2021] [Accepted: 01/08/2021] [Indexed: 12/13/2022] Open
Abstract
Heart failure-either with reduced or preserved ejection fraction (HFrEF/HFpEF)-is a clinical syndrome of multifactorial and gender-dependent aetiology, indicating the insufficiency of the heart to pump blood adequately to maintain blood flow to meet the body's needs. Typical symptoms commonly include shortness of breath, excessive fatigue with impaired exercise capacity, and peripheral oedema, thereby alluding to the fact that heart failure is a syndrome that affects multiple organ systems. Patients suffering from progressed heart failure have a very limited life expectancy, lower than that of numerous cancer types. In this position paper, we provide an overview regarding interactions between the heart and other organ systems, the clinical evidence, underlying mechanisms, potential available or yet-to-establish animal models to study such interactions and finally discuss potential new drug interventions to be developed in the future. Our working group suggests that more experimental research is required to understand the individual molecular mechanisms underlying heart failure and reinforces the urgency for tailored therapeutic interventions that target not only the heart but also other related affected organ systems to effectively treat heart failure as a clinical syndrome that affects and involves multiple organs.
Collapse
Affiliation(s)
- Michele Ciccarelli
- University of Salerno, Department of Medicine, Surgery and Dentistry, Via S. Allende 1, 84081, Baronissi(Salerno), Italy
| | - Dana Dawson
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen AB25 2DZ, UK
| | - Inês Falcao-Pires
- Department of Surgery and Physiology, Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Mauro Giacca
- King’s College London, Molecular Medicine Laboratory, 125 Caldharbour Lane, London WC2R2LS, United Kingdom
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Padriciano, 99, 34149 Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume, 447, 34129 Trieste, Italy
| | - Nazha Hamdani
- Department of Clinical Pharmacology and Molecular Cardiology, Institute of Physiology, Ruhr University Bochum, Universitätsstraße 150, D-44801 Bochum, Germany
- Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Universitätsstraße 150, D-44801 Bochum, Germany
| | - Stéphane Heymans
- Centre for Molecular and Vascular Biology, KU Leuven, Herestraat 49, Bus 911, 3000 Leuven, Belgium
- Department of Cardiology, Maastricht University, CARIM School for Cardiovascular Diseases, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands
- ICIN-Netherlands Heart Institute, Holland Heart House, Moreelsepark 1, 3511 EP Utrecht, the Netherlands
| | - Astrid Hooghiemstra
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam UMC, Location VUmc, De Boelelaan 1089a, 1081HV, Amsterdam, The Netherlands
| | - Annebet Leeuwis
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands
| | - Dorien Hermkens
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | - Jolanda van der Velden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081HZ Amsterdam, the Netherlands
| | - Serena Zacchigna
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume, 447, 34129 Trieste, Italy
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Padriciano, 99, 34149 Trieste, Italy
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
- REBIRTH Center for Translational Regenerative Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine, Nicolai-Fuchs-Str. 1, D-30625 Hannover, Germany
| |
Collapse
|
19
|
Karoli NA, Rebrov AP. [Possibilities and limitations of the use of beta-blockers in patients with cardiovascular disease and chronic obstructive pulmonary disease]. KARDIOLOGIIA 2021; 61:89-98. [PMID: 34763643 DOI: 10.18087/cardio.2021.10.n1119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/29/2020] [Indexed: 06/13/2023]
Abstract
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).
Collapse
Affiliation(s)
- N A Karoli
- Saratov State Medical University Saratov, Russia
| | - A P Rebrov
- Saratov State Medical University Saratov, Russia
| |
Collapse
|
20
|
Karimi L, Lahousse L, De Nocker P, Stricker BH, Brusselle GG, Verhamme KMC. Effect of β-blockers on the risk of COPD exacerbations according to indication of use: the Rotterdam Study. ERJ Open Res 2021; 7:00624-2020. [PMID: 34195251 PMCID: PMC8236616 DOI: 10.1183/23120541.00624-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 02/16/2021] [Indexed: 11/24/2022] Open
Abstract
Observational studies report a reduction of COPD exacerbations in patients treated with β-blockers. In contrast, the Beta-Blockers for the Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease (BLOCK COPD) randomised controlled trial which excluded COPD patients with cardiovascular conditions showed an increase in COPD exacerbations. It is unclear whether this discrepancy could be explained by underlying cardiovascular comorbidity. We examined whether the association between use of β-blockers and risk of COPD exacerbations differed between patients with and without a cardiovascular indication for β-blockers use. Within the Rotterdam Study, we followed COPD subjects until the first COPD exacerbation, or end of follow-up. Cardiovascular indication for β-blockers use was defined as a history of hypertension, coronary heart disease, atrial fibrillation and/or heart failure at baseline. The association between β-blockers use and COPD exacerbations was assessed using Cox proportional hazards models adjusted for age, sex, smoking, incident cardiovascular disease (i.e. heart failure, hypertension, atrial fibrillation and/or coronary heart disease during follow-up), respiratory drugs and nitrates. In total, 1312 COPD patients with a mean age of 69.7±9.2 years were included. In patients with a cardiovascular indication (n=755, mean age of 70.4±8.8 years), current use of cardioselective β-blockers was significantly associated with a reduced risk of COPD exacerbations (HR 0.69, 95% CI 0.57–0.85). In contrast, in subjects without a cardiovascular indication (n=557, mean age of 68.8±9.7 years), current use of cardioselective β-blockers was not associated with an altered risk of COPD exacerbations (HR 0.94, 95% CI 0.55–1.62). Use of cardioselective β-blockers reduced the risk of exacerbations in COPD patients with concomitant cardiovascular disease. Therefore, the potential benefits of β-blockers might be confined to COPD patients with cardiovascular disease. Use of cardioselective β-blockers reduces the risk of COPD exacerbations in patients with concomitant cardiovascular disease. The potential benefits of β-blockers might be restricted to COPD patients with cardiovascular disease.https://bit.ly/3bB1RGg
Collapse
Affiliation(s)
- Leila Karimi
- Dept of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lies Lahousse
- Dept of Bioanalysis, Ghent University, Ghent, Belgium.,Dept of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Bruno H Stricker
- Dept of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Dept of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Guy G Brusselle
- Dept of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.,Dept of Respiratory Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Katia M C Verhamme
- Dept of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands.,Dept of Bioanalysis, Ghent University, Ghent, Belgium
| |
Collapse
|
21
|
Zysman M, Ribeiro Baptista B, Soumagne T, Marques da Silva V, Martin C, Thibault de Menonville C, Boyer L, Degano B, Morelot Panzini C, Burgel PR, Perez T, Bourdin A, Raherison C, Pégliasco H, Piperno D, Zanetti C, Morel H, Delclaux B, Delafosse C, Lorenzo A, Housset B, Chabot F, Devillier P, Deslée G, Roche N. [Pharmacological treatment optimisation in patients with stale COPD. Position of the French-language Respiratory Society. 2021 Update]. Rev Mal Respir 2021; 38:539-561. [PMID: 33985869 DOI: 10.1016/j.rmr.2021.02.070] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 02/21/2021] [Indexed: 01/19/2023]
Affiliation(s)
- M Zysman
- Université Bordeaux, centre de recherche cardiothoracique de Bordeaux, U1045, CIC 1401, 33604 Pessac, France; Service des maladies respiratoires, CHU Bordeaux, Bordeaux, France.
| | - B Ribeiro Baptista
- Université Paris-Est, UMR S955, UPEC, 94000 Créteil, France; Département de pneumologie, CHRU Nancy, université de Lorraine, Inserm, U1116, université de Lorraine, Nancy/Vandœuvre-lès-Nancy, France
| | - T Soumagne
- Service de pneumologie, oncologie thoracique et allergologie respiratoire, CHU de Besançon, Besançon, France
| | | | - C Martin
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| | | | - L Boyer
- Université Paris-Est, UMR S955, UPEC, 94000 Créteil, France; Département de physiologie-explorations fonctionnelles, AP-HP, hôpital Henri-Mondor, Paris, France
| | - B Degano
- Service hospitalier universitaire pneumologie physiologie, pôle thorax et vaisseaux, CHU Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Grenoble, France
| | - C Morelot Panzini
- Sorbonne Université, AP-HP, Service de Pneumologie, Médecine Intensive et Réanimation, Pitié-Salpêtrière Hospital, Paris, France
| | - P R Burgel
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| | - T Perez
- Service de pneumologie, CHU Lille, institut Pasteur de Lille, U1019, UMR9017, centre d'infection et d'immunité de Lille (CIIL), Lille, France
| | - A Bourdin
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France; Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, Montpellier, France
| | - C Raherison
- Service des maladies respiratoires, CHU Bordeaux, Bordeaux, France; Bordeaux Population Health Research Center, université Bordeaux, INSERM, Team EPICENE, UMR 1219, Bordeaux, France
| | - H Pégliasco
- Service de pneumologie, hôpital européen, Marseille, France
| | | | - C Zanetti
- Cabinet de pneumologie, 62300 Lens, France
| | - H Morel
- Service de pneumologie d'allergologie et d'oncologie thoracique, CHR d'Orléans, 45067 Orléans, France
| | - B Delclaux
- Service de pneumologie, centre hospitalier de Troyes, 10003 Troyes, France
| | - C Delafosse
- Centre hospitaliser Simone-Veil, 95602 Eaubonne, France
| | - A Lorenzo
- Médecine Sorbonne université, département de médecine générale, Paris, France
| | - B Housset
- Département de pneumologie, CHI de Créteil, University Paris Est Créteil, Créteil, France
| | - F Chabot
- Département de pneumologie, CHRU Nancy, université de Lorraine, Inserm, U1116, université de Lorraine, Nancy/Vandœuvre-lès-Nancy, France
| | - P Devillier
- Department of Airway Diseases, VIM-Suresnes, UMR0892, Foch Hospital, Paris-Saclay University, Suresnes, France
| | - G Deslée
- Service de pneumologie, Inserm U1250, CHU Reims, université Reims Champagne Ardenne, Reims, France
| | - N Roche
- Department of Respir Med, Cochin Hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France; INSERM U1016, Institut Cochin, Paris, France
| |
Collapse
|
22
|
Beta blockers still relevant. COR ET VASA 2021. [DOI: 10.33678/cor.2021.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
23
|
MacLeod M, Papi A, Contoli M, Beghé B, Celli BR, Wedzicha JA, Fabbri LM. Chronic obstructive pulmonary disease exacerbation fundamentals: Diagnosis, treatment, prevention and disease impact. Respirology 2021; 26:532-551. [PMID: 33893708 DOI: 10.1111/resp.14041] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In chronic obstructive pulmonary disease (COPD), exacerbations (ECOPD), characterized by an acute deterioration in respiratory symptoms, are fundamental events impacting negatively upon disease progression, comorbidities, wellbeing and mortality. ECOPD also represent the largest component of the socioeconomic burden of COPD. ECOPDs are currently defined as acute worsening of respiratory symptoms that require additional therapy. Definitions that require worsening of dyspnoea and sputum volume/purulence assume that acute infections, especially respiratory viral infections, and/or exposure to pollutants are the main cause of ECOPD. But other factors may contribute to ECOPD, such as the exacerbation of other respiratory diseases and non-respiratory diseases (e.g., heart failure, thromboembolism). The complexity of worsening dyspnoea has suggested a need to improve the definition of ECOPD using objective measurements such as blood counts and C-reactive protein to improve accuracy of diagnosis and a personalized approach to management. There are three time points when we can intervene to improve outcomes: acutely, to attenuate the length and severity of an established exacerbation; in the aftermath, to prevent early recurrence and readmission, which are common, and in the long-term, establishing preventative measures that reduce the risk of future events. Acute management includes interventions such as corticosteroids or antibiotics and measures to support the respiratory system, including non-invasive ventilation (NIV). Current therapies are broad and better understanding of clinical phenotypes and biomarkers may help to establish a more tailored approach, for example in relation to antibiotic prescription. Other unmet needs include effective treatment for viruses, which commonly cause exacerbations. Preventing early recurrence and readmission to hospital is important and the benefits of interventions such as antibiotics or anti-inflammatories in this period are not established. Domiciliary NIV in those patients who are persistently hypercapnic following discharge and pulmonary rehabilitation can have a positive impact. For long-term prevention, inhaled therapy is key. Dual bronchodilators reduce exacerbation frequency but in patients with continuing exacerbations, triple therapy should be considered, especially if blood eosinophils are elevated. Other options include phosphodiesterase inhibitors and macrolide antibiotics. ECOPD are a key component of the assessment of COPD severity and future outcomes (quality of life, hospitalisations, health care resource utilization, mortality) and are a central component in pharmacological management decisions. Targeted therapies directed towards specific pathways of inflammation are being explored in exacerbation prevention, and this is a promising avenue for future research.
Collapse
Affiliation(s)
- Mairi MacLeod
- National Heart and Lung Institute, Imperial College, London, UK
| | - Alberto Papi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Contoli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Bianca Beghé
- Department of Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Leonardo M Fabbri
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.,Department of Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
24
|
Beta-blocker therapy in patients with COPD: a systematic literature review and meta-analysis with multiple treatment comparison. Respir Res 2021; 22:64. [PMID: 33622362 PMCID: PMC7903749 DOI: 10.1186/s12931-021-01661-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/10/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Beta-blockers are associated with reduced mortality in patients with cardiovascular disease but are often under prescribed in those with concomitant COPD, due to concerns regarding respiratory side-effects. We investigated the effects of beta-blockers on outcomes in patients with COPD and explored within-class differences between different agents. METHODS We searched the Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline for observational studies and randomized controlled trials (RCTs) investigating the effects of beta-blocker exposure versus no exposure or placebo, in patients with COPD, with and without cardiovascular indications. A meta-analysis was performed to assess the association of beta-blocker therapy with acute exacerbations of COPD (AECOPD), and a network meta-analysis was conducted to investigate the effects of individual beta-blockers on FEV1. Mortality, all-cause hospitalization, and quality of life outcomes were narratively synthesized. RESULTS We included 23 observational studies and 14 RCTs. In pooled observational data, beta-blocker therapy was associated with an overall reduced risk of AECOPD versus no therapy (HR 0.77, 95%CI 0.70 to 0.85). Among individual beta-blockers, only propranolol was associated with a relative reduction in FEV1 versus placebo, among 199 patients evaluated in RCTs. Narrative syntheses on mortality, all-cause hospitalization and quality of life outcomes indicated a high degree of heterogeneity in study design and patient characteristics but suggested no detrimental effects of beta-blocker therapy on these outcomes. CONCLUSION The class effect of beta-blockers remains generally positive in patients with COPD. Reduced rates of AECOPD, mortality, and improved quality of life were identified in observational studies, while propranolol was the only agent associated with a deterioration of lung function in RCTs.
Collapse
|
25
|
Beta-blockers in chronic obstructive pulmonary disease: the good, the bad and the ugly. Curr Opin Pulm Med 2020; 27:125-131. [PMID: 33332878 DOI: 10.1097/mcp.0000000000000748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Several observational studies have suggested that β-blockers, especially cardioselective ones, are well tolerated and associated with a lower risk of acute exacerbations and death in patients with chronic obstructive pulmonary disease (COPD). However, there are dissenting studies. This review provides an update on the use of β-blockers in COPD, focusing on results of recent prospective studies and randomized controlled trials. RECENT FINDINGS In totality, cohort studies indicate that β-blockers are generally well tolerated and effective in COPD patients who also have a clear cardiovascular indication for these medications. Although β-blockers on average reduce lung function acutely in COPD patients, the absolute decrease is relatively small, especially if cardioselective β-blockers are used. The results of two large randomized controlled trials suggest that β-blocker use does not reduce the therapeutic benefits of inhaled bronchodilators in COPD patients. The use of β-blockers in COPD patients, who do not have overt cardiovascular disease, does not prevent COPD exacerbations and may paradoxically increase the risk of COPD-related hospitalization and mortality. SUMMARY The use of β-blockers is generally well tolerated and effective in COPD patients, who also have a clear cardiovascular indication for these drugs. However, they should not be used in patients who do not have overt cardiovascular disease as β-blockers can reduce lung function, worsen health status and increase the risk of COPD-related hospitalization.
Collapse
|
26
|
Baou K, Katsi V, Makris T, Tousoulis D. Beta Blockers and Chronic Obstructive Pulmonary Disease (COPD): Sum of Evidence. Curr Hypertens Rev 2020; 17:196-206. [PMID: 33302840 DOI: 10.2174/1573402116999201209203250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Katerina Baou
- First Department of Pulmonary Medicine, Sismanoglio Hospital, Sismanogliou 1, Marousi,. Greece
| | - Vasiliki Katsi
- First Department of Cardiology, Hippokration Hospital, University of Athens, Vasilissis Sofias 114, Athens,. Greece
| | - Thomas Makris
- Department of Cardiology, Helena Venizelou Hospital, Helenas Venizelou 2 Square, Ampelokipi,. Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, University of Athens, Vasilissis Sofias 114, Athens,. Greece
| |
Collapse
|
27
|
Chang CH, Lin HC, Yang CH, Gan ST, Huang CH, Chung FT, Hu HC, Lin SM, Chang CH. Factors Associated with Exercise-Induced Desaturation in Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2020; 15:2643-2652. [PMID: 33122902 PMCID: PMC7591268 DOI: 10.2147/copd.s272511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/23/2020] [Indexed: 02/02/2023] Open
Abstract
Purpose The 6-min walk test (6MWT) is a useful tool to assess the physiologic function in patients with chronic obstructive pulmonary disease (COPD). The recent study showed that patients with COPD with oxygen desaturation during the 6MWT had an increased risk of exacerbation and death compared with those without oxygen desaturation. This study aimed to explore the potential risk factors for exercise-induced desaturation (EID) in patients with COPD. Patients and Methods Adult patients with COPD were enrolled from the Chang Gung Research Database between January 2013 and January 2017. Age, sex, body mass index, underlying diseases, medications, and results of the pulmonary function tests and 6MWT were retrospectively collected and analyzed. Results Among 1768 patients with COPD, 932 (52.7%) had oxygen desaturation, and the other 836 (47.3%) had no desaturation during the 6MWT. The patients with EID had a shorter 6-min walk distance than those without desaturation (352.08±120.29 vs 426.56±112.56, p<0.0001). In the multivariate logistic regression analysis, older age, female sex, lower forced expiratory volume in 1 s, and comorbidity with atrial fibrillation (AF) were associated with oxygen desaturation during the 6MWT. Patients with EID had higher exacerbation frequency than those without desaturation in the 1-year follow-up period (0.59±1.50 vs 0.34±1.26, p<0.0001). Patients with COPD with AF also had a higher rate of exacerbation requiring emergency department visit or hospitalization in the 1-year follow-up. Conclusion This study demonstrates that older age, low FEV1, and female sex are risk factors for EID. Desaturation during 6MWT is related to frequent acute exacerbation of COPD in the 1-year follow-up.
Collapse
Affiliation(s)
- Chiung-Hsin Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Horng-Chyuan Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Chia-Hung Yang
- Division of Cardiology, Department of Internal Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Shu-Ting Gan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Hsien Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Fu-Tsai Chung
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Shu-Min Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Chih-Hao Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| |
Collapse
|
28
|
Rasmussen DB, Bodtger U, Lamberts M, Torp-Pedersen C, Gislason G, Lange P, Jensen MT. Beta-blocker use and acute exacerbations of COPD following myocardial infarction: a Danish nationwide cohort study. Thorax 2020; 75:928-933. [PMID: 32820080 DOI: 10.1136/thoraxjnl-2019-214206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 06/17/2020] [Accepted: 06/29/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patients with chronic obstructive pulmonary disease (COPD) are undertreated with beta-blockers following myocardial infarction (MI), possibly due to fear for acute exacerbations of COPD (AECOPD). Is beta-blocker use associated with increased risk of AECOPD in patients following first-time MI? METHODS Danish nationwide study of patients with COPD following hospitalisation for MI from 2003 to 2015. Multivariable, time-dependent Cox regression accounting for varying beta-blocker use based on claimed prescriptions during up to 13 years of follow-up. RESULTS A total of 10 884 patients with COPD were discharged after first-time MI. The 1-year rate of AECOPD was 35%, and 65% used beta-blockers at 1 year. Beta-blocker use was associated with a lower risk of AECOPD (multivariable-adjusted HR 0.78, 95% CI 0.74-0.83). This association was independent of the type of MI (HR 0.70, 95% CI 0.59-0.83 in ST-elevation MI (STEMI) and HR 0.80, 95% CI 0.75-0.84 in non-STEMI), presence or absence of heart failure (HR 0.82, 95% CI 0.74-0.90 and HR 0.77, 95% CI 0.72-0.82, respectively), beta-blocker dosage and type, as well as exacerbation severity. Results were similar in 1118 patients with full data on COPD severity and symptom burden (median forced expiratory volume in 1 s as percentage of predicted was 46 and majority had moderate dyspnoea), and in 1358 patients with severe COPD and frequent AECOPD with a high 1-year rate of AECOPD of 70%. DISCUSSION Beta-blocker use was not associated with increased risk of AECOPD following MI. This finding was independent of COPD severity, symptom burden and exacerbation history, and supports the safety of beta-blockers in patients with COPD, including high-risk patients with severe disease.
Collapse
Affiliation(s)
- Daniel B Rasmussen
- Respiratory Research Unit Zealand, Department of Respiratory Medicine, Naestved Hospital, Naestved, Sjaelland, Denmark .,Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Uffe Bodtger
- Respiratory Research Unit Zealand, Department of Respiratory Medicine, Naestved Hospital, Naestved, Sjaelland, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Morten Lamberts
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Christian Torp-Pedersen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Gunnar Gislason
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark, Odense, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark
| | - Peter Lange
- Department of Internal Medicine, Section of Respiratory Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Magnus T Jensen
- William Harvey Research Institute, NIHR Barts Biomedical Centre, Queen Mary University of London, Charterhouse Square Campus, London, UK
| |
Collapse
|
29
|
COPD-effect of metoprolol in people with no proven cardiac indication. Drug Ther Bull 2020; 58:118. [PMID: 32447280 DOI: 10.1136/dtb.2020.000034] [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: 06/11/2023]
Abstract
Review of: Dransfield MT, Voelker H, Bhatt SP, et al Metoprolol for the prevention of acute exacerbations of COPD. N Engl J Med 2019;381:2304-14.
Collapse
|
30
|
Kostikas K, Rhee CK, Hurst JR, Agostoni P, Cao H, Fogel R, Jones R, Kocks JWH, Mezzi K, Wan Yau Ming S, Ryan R, Price DB. Adequacy of Therapy for People with Both COPD and Heart Failure in the UK: Historical Cohort Study. Pragmat Obs Res 2020; 11:55-66. [PMID: 32581622 PMCID: PMC7276330 DOI: 10.2147/por.s250451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/30/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Chronic obstructive pulmonary disease (COPD) and heart failure (HF) often occur concomitantly, presenting diagnostic and therapeutic challenges for clinicians. We examined the characteristics of patients prescribed adequate versus inadequate therapy within 3 months after newly diagnosed comorbid COPD or HF. Patients and Methods Eligible patients in longitudinal UK electronic medical record databases had pre-existing HF and newly diagnosed COPD (2017 GOLD groups B/C/D) or pre-existing COPD and newly diagnosed HF. Adequate COPD therapy was defined as long-acting bronchodilator(s) with/without inhaled corticosteroid; adequate HF therapy was defined as beta-blocker plus angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker. Results Of 2439 patients with HF and newly diagnosed COPD (mean 75 years, 61% men), adequate COPD therapy was prescribed for 726 (30%) and inadequate for 1031 (42%); 682 (28%) remained untreated for COPD. Adequate (vs inadequate) COPD therapy was less likely for women (35%) than men (45%), smokers (36%) than ex-/non-smokers (45%), and non-obese (41%) than obese (47%); spirometry was recorded for 57% prescribed adequate versus 35% inadequate COPD therapy. Of 12,587 patients with COPD and newly diagnosed HF (mean 75 years, 60% men), adequate HF therapy was prescribed for 2251 (18%) and inadequate for 5332 (42%); 5004 (40%) remained untreated for HF. Adequate (vs inadequate) HF therapy was less likely for smokers (27%) than ex-/non-smokers (32%) and non-obese (30%) than obese (35%); spirometry was recorded for 65% prescribed adequate versus 39% inadequate HF therapy. Conclusion Many patients with comorbid COPD/HF receive inadequate therapy after new diagnosis. Improved equity of access to integrated care is needed for all patient subgroups.
Collapse
Affiliation(s)
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Hui Cao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Robert Fogel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Rupert Jones
- Plymouth University, Faculty of Medicine and Dentistry, Plymouth, UK
| | - Janwillem W H Kocks
- Observational and Pragmatic Research Institute, Singapore, Singapore.,General Practitioners Research Institute, Groningen, the Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, Groningen, the Netherlands
| | | | | | - Ronan Ryan
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
31
|
Wade C, Wells JM. Practical recommendations for the use of beta-blockers in chronic obstructive pulmonary disease. Expert Rev Respir Med 2020; 14:671-678. [PMID: 32250198 DOI: 10.1080/17476348.2020.1752671] [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: 10/24/2022]
Abstract
INTRODUCTION Controversies regarding the use of beta-blocker in chronic obstructive pulmonary disease (COPD) have been longstanding and based on inconsistent data. COPD and cardiovascular disease have many shared risk factors and potentially overlapping pathophysiologic mechanisms. Beta-blockers, a mainstay of treatment in ischemic heart disease, congestive heart failure, and cardiac arrhythmia, remain underutilized in COPD patients despite considerable evidence of safety. Furthermore, observational studies indicated the potential benefits of beta-blockers in COPD via a variety of possible mechanisms. Recently, a randomized controlled trial of metoprolol versus placebo failed to show a reduction in COPD exacerbation risk in subjects with moderate to severe COPD and no absolute indication for beta-blocker use. AREAS COVERED Physiology of beta-adrenergic receptors, links between COPD and cardiovascular disease, and the role of beta-blockers in COPD management are discussed. EXPERT COMMENTARY Beta-blockers should not be used to treat COPD patients who do not have conditions with clear guideline-directed recommendations for their use. Vigilance is recommended in prescribing these medications for indications where another drug class could be utilized.
Collapse
Affiliation(s)
- Chad Wade
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham , Birmingham, AL, USA.,Lung Health Center , Birmingham, AL, USA
| | - J Michael Wells
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham , Birmingham, AL, USA.,Lung Health Center , Birmingham, AL, USA.,Acute Care Service, Birmingham VA Medical Center , Birmingham, AL, USA
| |
Collapse
|
32
|
Beta Adrenergic Blocker Use in Patients With Chronic Obstructive Pulmonary Disease and Concurrent Chronic Heart Failure With a Low Ejection Fraction. Cardiol Rev 2020; 28:20-25. [PMID: 31804289 DOI: 10.1097/crd.0000000000000284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) often coexist and present clinicians with diagnostic and therapeutic challenges. Beta-blockers are a cornerstone of CHF treatment, in patients with a low ejection fraction, while beta-agonists are utilized for COPD. These 2 therapies exert opposing pharmacological effects. COPD patients are at an increased risk of mortality from cardiovascular events. In addition to CHF, beta-blockers are used in a number of cardiovascular conditions because of their cardioprotective properties as well as their mortality benefit. However, there is reluctance among physicians to use beta-blockers in patients with COPD because of fear of inducing bronchospasms, despite increasing evidence of their safety and mortality benefits. The majority of this evidence comes from observational studies showing that beta-blockers are safe and well tolerated, with minimal effect on respiratory function. Furthermore, beta-blockers have been shown to lower the mortality risk in patients with COPD alone, as well as in those with COPD and CHF. Large clinical trials are needed in order to dispel the mistrust of beta-blocker use in COPD patients. The current evidence supports the use of cardioselective beta-blockers in patients with COPD. As the population continues to live longer, comorbidities become ever more present, and cardioselective beta-blockers should not be withheld from patients with COPD and coexistent CHF, because the benefits outweigh the risks.
Collapse
|
33
|
Li XF, Mao YM. Beta-blockers in COPD: A systematic review based on recent research. Life Sci 2020; 252:117649. [PMID: 32275936 DOI: 10.1016/j.lfs.2020.117649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/01/2020] [Accepted: 04/04/2020] [Indexed: 01/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) with cardiovascular complications is very common. Due to fear of exacerbating airway spasm, β-blockers are rarely used in such patients. Many observational studies suggest that β-blockers can reduce the disease progression and the risk of mortality in patients with COPD, but lack of confirmation from randomized controlled trials. This article reviews the application of β-blockers in patients with COPD based on the results of the latest published randomized controlled trials.
Collapse
Affiliation(s)
- Xiao-Fang Li
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China
| | - Yi-Min Mao
- Department of Respiratory Medicine, The First Affiliated Hospital/College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan Province, China.
| |
Collapse
|
34
|
The bidirectional relationship between chronic obstructive pulmonary disease and coronary artery disease. Herz 2020; 45:110-117. [DOI: 10.1007/s00059-020-04893-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
35
|
Zvizdic F, Begic E, Mujakovic A, Hodzic E, Prnjavorac B, Bedak O, Custovic F, Bradaric H, Durak-Nalbantic A. Beta-blocker Use in Moderate and Severe Chronic Obstructive Pulmonary Disease. Med Arch 2020; 73:72-75. [PMID: 31391690 PMCID: PMC6643359 DOI: 10.5455/medarh.2019.73.72-75] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction: The most appropriate choice of pharmacological treatment of heart rhythm disorders occurring in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular comorbidity is often a topic of debate between pulmonologists and cardiologists in clinical practice, although numerous studies and clinical trials have demonstrated evidence to support the use of selective beta-blockers (BBs) in these patients. Aim: To examine the difference in the number of exacerbations in patients treated with a combination of verapamil and digoxin or BB alone in patients with different COPD stages. Patients and methods: The study included 68 patients (n = 68) diagnosed with COPD who were followed-up during a 12-month period, and the number of exacerbations were analyzed. The patients were divided into two groups according to the stage of COPD: GOLD II (moderate), and GOLD III (severe), and in each group a subdivision was established in relation to the use of either a combination of verapamil and digoxin or the use of BBs alone in pharmacological treatment. The inclusion criteria for patients were defined as following: a) established diagnosis of COPD according to present or deteriorated relevant clinical symptoms and signs, b) the ejection fraction (EF) of a left ventricle (LV) >35%, and c) spirometric cut-points classified as GOLD II (FEV1 / FVC <0.7, FEV1 predicted 50-80%), or GOLD III (FEV1/FVC <0.7, FEV1 predicted 30-50%) stage of the COPD. The exclusion criteria were EF of LV <35% and a lethal outcome during a follow-up period (2 patients were encountered). Exacerbation was defined as functional deterioration of the COPD symptoms verified by spirometric functional testing, frequency of hospitalizations according to GOLD stage assignment or verified clinical symptoms deterioration. Results: Regardless the pharmacological treatment, there is a statistically significant increase in the number of COPD exacerbations, in a 12-month period follow-up, in the GOLD III group (severe) compared to the GOLD II group (moderate). In the group of patients taking verapamil and digoxin, a two-tailed t-test was used to analyze the results between the GOLD II and GOLD III stage groups, p = 0.01, and 2. In the group of patients taking BBs, a two-tailed t-test was also used to analyze the results between the GOLD II and GOLD III stage groups, p = 0.003). Within the COPD GOLD II stage group, there appears to be no statistically significant difference in the number of exacerbations between the patients taking verapamil and digoxin (n = 24) and the patients taking BBs alone (n = 15), although, in patients taking BBs alone, there appears to be a trend towards a decrease in the exacerbations compared to the number of exacerbations in patients taking verapamil and digoxin (p = 0.007). Within the COPD GOLD III stage group, there is no difference in the number of exacerbations between the patients taking verapamil and digoxin (n = 20), and the patients taking BBs alone (n = 9), as analyzed by a two-tailed t-test, p = 0.577. Conclusion: Use of selective BBs in the treatment of cardiovascular comorbidity in patients with COPD represents a far better choice of pharmacological approach in the treatment of patients diagnosed with COPD GOLD II (moderate) stage.
Collapse
Affiliation(s)
- Faris Zvizdic
- Department for Cardiology, Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Edin Begic
- Department of Pharmacology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina.,Department of Cardiology, General Hospital "Prim. Dr. Abdulah Nakas", Sarajevo, Bosnia and Herzegovina
| | - Aida Mujakovic
- Department of Pathophysiology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina.,Department of Pulmonary Diseases, General Hospital "Prim. Dr. Abdulah Nakas", Sarajevo, Bosnia and Herzegovina
| | - Enisa Hodzic
- Intensive Care Unit, Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Besim Prnjavorac
- Department of Pathophysiology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina.,Department of Internal Medicine, General Hospital, Tesanj, Bosnia and Herzegovina
| | - Omer Bedak
- Department of Internal Medicine, General Hospital, Tesanj, Bosnia and Herzegovina
| | - Faruk Custovic
- Department of Cardiology, General Hospital "Prim. Dr. Abdulah Nakas", Sarajevo, Bosnia and Herzegovina
| | - Haris Bradaric
- Health Care Centre Maglaj, Maglaj, Bosnia and Herzegovina
| | - Azra Durak-Nalbantic
- Department for Cardiology, Clinic for Heart, Blood Vessel and Rheumatic Diseases, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| |
Collapse
|
36
|
Pellicori P, Cleland JGF, Clark AL. Chronic Obstructive Pulmonary Disease and Heart Failure: A Breathless Conspiracy. Heart Fail Clin 2020; 16:33-44. [PMID: 31735313 DOI: 10.1016/j.hfc.2019.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are both common causes of breathlessness and often conspire to confound accurate diagnosis and optimal therapy. Risk factors (such as aging, smoking, and obesity) and clinical presentation (eg, cough and breathlessness on exertion) can be very similar, but the treatment and prognostic implications are very different. This review discusses the diagnostic challenges in individuals with exertional dyspnea. Also highlighted are the prevalence, clinical relevance, and therapeutic implications of a concurrent diagnosis of COPD and HF.
Collapse
Affiliation(s)
- Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK.
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School, University of Hull, Kingston upon Hull HU16 5JQ, UK
| |
Collapse
|
37
|
Bhatt SP. Acute Exacerbations of Chronic Lung Disease: Cardiac Considerations. CARDIAC CONSIDERATIONS IN CHRONIC LUNG DISEASE 2020. [PMCID: PMC7282481 DOI: 10.1007/978-3-030-43435-9_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The importance of appropriately recognizing and managing patients with cardiovascular and pulmonary comorbidities is underscored by the poor outcomes described in complex comorbid patients. Patients with chronic obstructive pulmonary disease (COPD) have an increased risk, up to one-third greater than the general population, of cardiovascular comorbidities including hypertension and diabetes [1].
Collapse
Affiliation(s)
- Surya P. Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| |
Collapse
|
38
|
Sundaram V, Quint JK. Chronic obstructive pulmonary disease and myocardial infarction: when will we get our act together? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 6:1-2. [PMID: 30980661 DOI: 10.1093/ehjqcco/qcz016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Varun Sundaram
- Department of Population Science, National Heart and Lung Institute, Manresa Road, London, SW3 6LR, UK
| | - Jennifer K Quint
- Department of Population Science, National Heart and Lung Institute, Manresa Road, London, SW3 6LR, UK
| |
Collapse
|
39
|
Vahdatpour CA, Luebbert JJ, Palevsky HI. Atrial arrhythmias in chronic lung disease-associated pulmonary hypertension. Pulm Circ 2020; 10:2045894020910685. [PMID: 32215200 PMCID: PMC7065292 DOI: 10.1177/2045894020910685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022] Open
Abstract
Atrial arrhythmias are common during episodes of acute respiratory failure in patients with chronic lung disease-associated pulmonary hypertension. Expert opinion suggests that management of atrial arrhythmias in patients with pulmonary hypertension should aim to restore sinus rhythm. This is clinically challenging in pulmonary hypertension patients with coexisting chronic lung disease, as there is controversy on the use of rhythm control agents; generally, in regard to either their pulmonary toxicity profile or the lack of evidence supporting their use. Rate control methods are largely focused on the use of beta blockers and calcium channel blockers. Concerns regarding their use involve their negative inotropic properties in cor pulmonale, the risk of bronchospasm associated with beta blockers, and the potential for ventilation/perfusion mismatching associated with calcium channel blockers. While digoxin has been associated with promising outcomes during acute right ventricular failure, there is limited evidence to suggest its routine use. Electrical cardioversion is associated with a high failure rate and it frequently requires multiple attempts. Radiofrequency catheter ablation is a more definitive approach, but concerns surrounding mechanical ventilation and sedation limit its applicability in decompensated pulmonary hypertension. Individual approaches are needed to address atrial arrhythmia management during acute episodes of respiratory failure.
Collapse
Affiliation(s)
- Cyrus A. Vahdatpour
- Department of Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Jeffrey J. Luebbert
- Department of Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Harold I. Palevsky
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
40
|
Singh J. Beta-blockers: A tale of triumphs, trials, and tribulations. Int J Appl Basic Med Res 2020; 10:1-2. [PMID: 32002376 PMCID: PMC6967340 DOI: 10.4103/ijabmr.ijabmr_418_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
41
|
Dransfield MT, Voelker H, Bhatt SP, Brenner K, Casaburi R, Come CE, Cooper JAD, Criner GJ, Curtis JL, Han MK, Hatipoğlu U, Helgeson ES, Jain VV, Kalhan R, Kaminsky D, Kaner R, Kunisaki KM, Lambert AA, Lammi MR, Lindberg S, Make BJ, Martinez FJ, McEvoy C, Panos RJ, Reed RM, Scanlon PD, Sciurba FC, Smith A, Sriram PS, Stringer WW, Weingarten JA, Wells JM, Westfall E, Lazarus SC, Connett JE. Metoprolol for the Prevention of Acute Exacerbations of COPD. N Engl J Med 2019; 381:2304-2314. [PMID: 31633896 PMCID: PMC7416529 DOI: 10.1056/nejmoa1908142] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Observational studies suggest that beta-blockers may reduce the risk of exacerbations and death in patients with moderate or severe chronic obstructive pulmonary disease (COPD), but these findings have not been confirmed in randomized trials. METHODS In this prospective, randomized trial, we assigned patients between the ages of 40 and 85 years who had COPD to receive either a beta-blocker (extended-release metoprolol) or placebo. All the patients had a clinical history of COPD, along with moderate airflow limitation and an increased risk of exacerbations, as evidenced by a history of exacerbations during the previous year or the prescribed use of supplemental oxygen. We excluded patients who were already taking a beta-blocker or who had an established indication for the use of such drugs. The primary end point was the time until the first exacerbation of COPD during the treatment period, which ranged from 336 to 350 days, depending on the adjusted dose of metoprolol. RESULTS A total of 532 patients underwent randomization. The mean (±SD) age of the patients was 65.0±7.8 years; the mean forced expiratory volume in 1 second (FEV1) was 41.1±16.3% of the predicted value. The trial was stopped early because of futility with respect to the primary end point and safety concerns. There was no significant between-group difference in the median time until the first exacerbation, which was 202 days in the metoprolol group and 222 days in the placebo group (hazard ratio for metoprolol vs. placebo, 1.05; 95% confidence interval [CI], 0.84 to 1.32; P = 0.66). Metoprolol was associated with a higher risk of exacerbation leading to hospitalization (hazard ratio, 1.91; 95% CI, 1.29 to 2.83). The frequency of side effects that were possibly related to metoprolol was similar in the two groups, as was the overall rate of nonrespiratory serious adverse events. During the treatment period, there were 11 deaths in the metoprolol group and 5 in the placebo group. CONCLUSIONS Among patients with moderate or severe COPD who did not have an established indication for beta-blocker use, the time until the first COPD exacerbation was similar in the metoprolol group and the placebo group. Hospitalization for exacerbation was more common among the patients treated with metoprolol. (Funded by the Department of Defense; BLOCK COPD ClinicalTrials.gov number, NCT02587351.).
Collapse
Affiliation(s)
- Mark T Dransfield
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Helen Voelker
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Surya P Bhatt
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Keith Brenner
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Richard Casaburi
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Carolyn E Come
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - J Allen D Cooper
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Gerard J Criner
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Jeffrey L Curtis
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - MeiLan K Han
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Umur Hatipoğlu
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Erika S Helgeson
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Vipul V Jain
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Ravi Kalhan
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - David Kaminsky
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Robert Kaner
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Ken M Kunisaki
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Allison A Lambert
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Matthew R Lammi
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Sarah Lindberg
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Barry J Make
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Fernando J Martinez
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Charlene McEvoy
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Ralph J Panos
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Robert M Reed
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Paul D Scanlon
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Frank C Sciurba
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Anthony Smith
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Peruvemba S Sriram
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - William W Stringer
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Jeremy A Weingarten
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - J Michael Wells
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Elizabeth Westfall
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - Stephen C Lazarus
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| | - John E Connett
- From the Lung Health Center, University of Alabama at Birmingham (M.T.D., S.P.B., J.M.W., E.W.), and Birmingham Veterans Affairs (VA) Medical Center (M.T.D., J.A.D.C., J.M.W.) - both in Birmingham; the University of Minnesota (H.V., E.S.H., S.L., J.E.C.) and the Minneapolis VA Medical Center (K.M.K.), Minneapolis, HealthPartners Minnesota, Bloomington (C.M.), and Mayo Clinic, Rochester (P.D.S.) - all in Minnesota; New York-Presbyterian (NYP)-Columbia University Medical Center (K.B.), NYP-Weill Cornell Medical Center (R. Kaner, F.J.M.), NYP-Queens Medical Center (A.S.), and NYP-Brooklyn Methodist Medical Center (J.A.W.) - all in New York; Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Los Angeles (R.C., W.W.S.), the University of California, San Francisco-Fresno, Fresno (V.V.J.), and the University of California, San Francisco, San Francisco (S.C.L.) - all in California; Brigham and Women's Hospital, Boston (C.E.C.); Temple University School of Medicine, Philadelphia (G.J.C.); the Ann Arbor VA Medical Center (J.L.C.) and the University of Michigan Health System (M.K.H.) - both in Ann Arbor; the Cleveland Clinic, Cleveland (U.H.); Northwestern University, Chicago (R. Kalhan); the University of Vermont, Burlington (D.K.); the University of Washington, Seattle (A.A.L.); Louisiana State University, New Orleans (M.R.L.); National Jewish Health, Denver (B.J.M.); the Cincinnati VA Medical Center, Cincinnati (R.J.P.); the University of Maryland, Baltimore (R.M.R.); the University of Pittsburgh, Pittsburgh (F.C.S.); and North Florida-South Georgia Veterans Health System, Gainesville (P.S.S.)
| |
Collapse
|
42
|
Abstract
Chronic obstructive pulmonary disease (COPD) can be a disabling disease, and the impact on older adults is particularly evident in the nursing home setting. Chronic obstructive pulmonary disease is present in about 20% of nursing home residents, most often in women, and accounts for significant healthcare utilization including acute care visits for exacerbations and pneumonia, as well as worsening heart disease and diabetes mellitus. The emphasis on hospital readmissions is particularly important in nursing homes where institutions have quality measures that have financial implications. Optimizing drug therapies in individuals with COPD involves choosing medications that not only improve symptoms, but also decrease the risk of exacerbations. Optimizing the treatment of comorbidities such as heart disease, infections, and diabetes that may affect COPD outcomes is also an important consideration. Depending on the nursing home setting and the patient, the options for optimizing COPD drug therapies may be limited owing to patient-related factors such as cognition and physical impairment or available resources, primarily reimbursement-related issues. Choosing the best drug therapy for COPD in older adults is limited by the difficulty in assessing respiratory symptoms using standardized assessment tools and potentially decreased inspiratory ability of frail individuals. Because of cognitive and physical impediments, ensuring optimal delivery of inhaled medications into the lungs has significant challenges. Long-acting bronchodilators, inhaled corticosteroids, and roflumilast decrease the risk of exacerbations, although inhaled corticosteroids should be used judiciously in this population because of the risk of pneumonia and oropharyngeal side effects. Treatment of COPD exacerbations should occur early and consideration should be made to the benefits and risks of systemic corticosteroids and antibiotics. Clinical research in the COPD population in nursing homes is clearly lacking, and ripe for discovery of effective management strategies.
Collapse
|
43
|
Abstract
The use of beta-blockers in patients with chronic obstructive pulmonary disease (COPD) has received much attention. Several observational studies reported important reductions in mortality and exacerbations with these drugs, but the extent of bias in these studies is unclear. Nevertheless, the large ongoing randomized trial (βLOCK-COPD) was initiated specifically to evaluate these effects. We searched the literature to identify all observational studies investigating the effectiveness of beta-blockers in COPD patients on major outcomes, including death and COPD exacerbation. We identified 18 observational studies, with 10 studies affected by confounding bias and six by immortal time bias, while two addressed these biases. Reductions in all-cause mortality with beta-blocker use were observed among the studies with confounding bias (pooled rate ratio 0.72; 95% CI 0.59-0.88) and those with immortal time bias (pooled rate ratio 0.64; 95% CI 0.53-0.77). A large five-database study that addressed these two biases reported hazard ratios of 0.90 (95% CI: 0.78-1.02) for death and 0.54 (95% CI: 0.47-0.61) for COPD hospitalization. However, this latter estimate was the same as for the first 30 days after treatment initiation, thus indicating that important residual confounding cannot be ruled out. Observational studies, important to provide evidence from real-world data on medication effects, are unsupportive for beta-blockers in COPD. Even if immortal time bias is properly avoided, confounding bias cannot be fully controlled due to their relative contraindication in COPD. In the case of beta-blockers, randomized trials such as βLOCK-COPD are necessary to eliminate the uncertainty from residual confounding bias.
Collapse
Affiliation(s)
- Samy Suissa
- a Center for Clinical Epidemiology, Lady Davis Institute - Jewish General Hospital , Montreal , Canada.,b Departments of Epidemiology and Biostatistics and of Medicine , McGill University , Montreal , Canada
| | - Pierre Ernst
- b Departments of Epidemiology and Biostatistics and of Medicine , McGill University , Montreal , Canada
| |
Collapse
|
44
|
Canepa M, Franssen FME, Olschewski H, Lainscak M, Böhm M, Tavazzi L, Rosenkranz S. Diagnostic and Therapeutic Gaps in Patients With Heart Failure and Chronic Obstructive Pulmonary Disease. JACC-HEART FAILURE 2019; 7:823-833. [PMID: 31521680 DOI: 10.1016/j.jchf.2019.05.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/26/2019] [Accepted: 05/11/2019] [Indexed: 12/31/2022]
Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) coincide in a significant number of patients. Recent population-based registries suggest that spirometry is largely underused in patients with HF to diagnose comorbid COPD and that patients with COPD frequently do not receive the recommended beta-blocker (BB) treatment. This state-of-the-art review summarizes: 1) current challenges in the implementation of recommended spirometry for COPD diagnosis in patients with HF; and 2) current underuse and underdosing of BBs in patients with HF and COPD despite guideline recommendations. Open issues in the therapeutic management of patients with HF and COPD are discussed in the third section, including the use of the nonselective BB carvedilol, target BB doses in patients with HF and COPD, BB and bronchodilator management during HF hospitalization with and without COPD exacerbation, and the use of BBs in patients with COPD with right HF or free from cardiovascular disease. The whole scenario described herein advocates for a bipartisan initiative to drive immediate attention to the translation of guideline recommendations into clinical practice for patients with HF with co-occurring COPD.
Collapse
Affiliation(s)
- Marco Canepa
- Cardiovascular Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Frits M E Franssen
- CIRO, Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Horst Olschewski
- Medical University of Graz, Department of Internal Medicine, Division of Pulmonology, Graz, Austria
| | - Mitja Lainscak
- Faculty of Medicine, University of Ljubljana and Department of Internal Medicine, General Hospital Murska Sobota, Ljubljana, Slovenia
| | - Michael Böhm
- Saarland University Medical Center, Homburg, Germany
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Cardiology) and Center for Molecular Medicine, University of Cologne, Cologne, Germany; Cologne Cardiovascular Research Center, University of Cologne, Cologne, Germany
| |
Collapse
|
45
|
Rosenkranz S, Bauersachs J. Cardiopulmonary interaction in heart or lung disease: physiology, disturbances, and their clinical implications. Herz 2019; 44:475-476. [PMID: 31485719 DOI: 10.1007/s00059-019-4832-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- S Rosenkranz
- Klinik III für Innere Medizin, Herzzentrum der Universität zu Köln, Kerpener Str. 62, 50937, Cologne, Germany.
| | - J Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hanover, Germany
| |
Collapse
|
46
|
Maselli DJ, Bhatt SP, Anzueto A, Bowler RP, DeMeo DL, Diaz AA, Dransfield MT, Fawzy A, Foreman MG, Hanania NA, Hersh CP, Kim V, Kinney GL, Putcha N, Wan ES, Wells JM, Westney GE, Young KA, Silverman EK, Han MK, Make BJ. Clinical Epidemiology of COPD: Insights From 10 Years of the COPDGene Study. Chest 2019; 156:228-238. [PMID: 31154041 PMCID: PMC7198872 DOI: 10.1016/j.chest.2019.04.135] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/08/2019] [Accepted: 04/28/2019] [Indexed: 12/16/2022] Open
Abstract
The Genetic Epidemiology of COPD (COPDGene) study is a noninterventional, multicenter, longitudinal analysis of > 10,000 subjects, including smokers with a ≥ 10 pack-year history with and without COPD and healthy never smokers. The goal was to characterize disease-related phenotypes and explore associations with susceptibility genes. The subjects were extensively phenotyped with the use of comprehensive symptom and comorbidity questionnaires, spirometry, CT scans of the chest, and genetic and biomarker profiling. The objective of this review was to summarize the major advances in the clinical epidemiology of COPD from the first 10 years of the COPDGene study. We highlight the influence of age, sex, and race on the natural history of COPD, and the impact of comorbid conditions, chronic bronchitis, exacerbations, and asthma/COPD overlap.
Collapse
Affiliation(s)
- Diego J Maselli
- Division of Pulmonary Diseases and Critical Care, UT Health San Antonio, and South Texas Veterans Health System, San Antonio, TX
| | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Antonio Anzueto
- Division of Pulmonary Diseases and Critical Care, UT Health San Antonio, and South Texas Veterans Health System, San Antonio, TX
| | - Russell P Bowler
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Dawn L DeMeo
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alejandro A Diaz
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mark T Dransfield
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Ashraf Fawzy
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marilyn G Foreman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX
| | - Craig P Hersh
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor Kim
- Department of Thoracic Medicine and Surgery, Temple University School of Medicine, Philadelphia, PA
| | - Gregory L Kinney
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| | - Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily S Wan
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; VA Boston Healthcare System, Jamaica Plain, MA
| | - J Michael Wells
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Gloria E Westney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Morehouse School of Medicine, Atlanta, GA
| | - Kendra A Young
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| | - Edwin K Silverman
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Barry J Make
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
| |
Collapse
|
47
|
Management of Comorbid Chronic Obstructive Pulmonary Disease and Cardiovascular Disease. Moving Past the Agony of the β-Receptor Debate. Ann Am Thorac Soc 2019; 15:558-559. [PMID: 29714105 DOI: 10.1513/annalsats.201802-090ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
48
|
Yii ACA, Loh CH, Tiew PY, Xu H, Taha AAM, Koh J, Tan J, Lapperre TS, Anzueto A, Tee AKH. A clinical prediction model for hospitalized COPD exacerbations based on "treatable traits". Int J Chron Obstruct Pulmon Dis 2019; 14:719-728. [PMID: 30988606 PMCID: PMC6443227 DOI: 10.2147/copd.s194922] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Assessing risk of future exacerbations is an important component in COPD management. History of exacerbation is a strong and independent predictor of future exacerbations, and the criterion of ≥2 nonhospitalized or ≥1 hospitalized exacerbation is often used to identify high-risk patients in whom therapy should be intensified. However, other factors or "treatable traits" also contribute to risk of exacerbation. Objective The objective of the study was to develop and externally validate a novel clinical prediction model for risk of hospitalized COPD exacerbations based on both exacerbation history and treatable traits. Patients and methods A total of 237 patients from the COPD Registry of Changi General Hospital, Singapore, aged 75±9 years and with mean post-bronchodilator FEV1 60%±20% predicted, formed the derivation cohort. Hospitalized exacerbation rate was modeled using zero-inflated negative binomial regression. Calibration was assessed by graphically comparing the agreement between predicted and observed annual hospitalized exacerbation rates. Predictive (discriminative) accuracy of the model for identifying high-risk patients (defined as experiencing ≥1 hospitalized exacerbations) was assessed with area under the curve (AUC) and receiver operating characteristics analyses, and compared to other existing risk indices. We externally validated the prediction model using a multicenter dataset comprising 419 COPD patients. Results The final model included hospitalized exacerbation rate in the previous year, history of acute invasive/noninvasive ventilation, coronary artery disease, bronchiectasis, and sputum nontuberculous mycobacteria isolation. There was excellent agreement between predicted and observed annual hospitalized exacerbation rates. AUC was 0.789 indicating good discriminative accuracy, and was significantly higher than the AUC of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) risk assessment criterion (history of ≥1 hospitalized exacerbation in the previous year) and the age, dyspnea, and obstruction index. When applied to the independent multicenter validation cohort, the model was well-calibrated and discrimination was good. Conclusion We have derived and externally validated a novel risk prediction model for COPD hospitalizations which outperforms several other risk indices. Our model incorporates several treatable traits which can be targeted for intervention to reduce risk of future hospitalized exacerbations.
Collapse
Affiliation(s)
- Anthony C A Yii
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore,
| | - C H Loh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore,
| | - P Y Tiew
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
- Translational Respiratory Research Laboratory, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Huiying Xu
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Aza A M Taha
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore,
| | - Jansen Koh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore,
| | - Jessica Tan
- Department of General Medicine, Sengkang General Hospital, Singapore
| | - Therese S Lapperre
- Department of Respiratory Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Duke-National University of Singapore Medical School, Singapore
| | - Antonio Anzueto
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, UT Health Science Center, San Antonio, TX, USA
| | - Augustine K H Tee
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore,
| |
Collapse
|
49
|
Su TH, Chang SH, Kuo CF, Liu PH, Chan YL. β-blockers after acute myocardial infarction in patients with chronic obstructive pulmonary disease: A nationwide population-based observational study. PLoS One 2019; 14:e0213187. [PMID: 30835781 PMCID: PMC6400336 DOI: 10.1371/journal.pone.0213187] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/17/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) less often receive β-blockers after acute myocardial infarction (AMI). This may influence their outcomes after AMI. This study evaluated the efficacy of β-blockers after AMI in patients with COPD, compared with non-dihydropyridine calcium channel blockers (NDCCBs) and absence of these two kinds of treatment. METHODS AND RESULTS We conducted a nationwide population-based cohort study using data retrieved from Taiwan National Health Insurance Research Database. We collected 28,097 patients with COPD who were hospitalized for AMI between January 2004 and December 2013. After hospital discharge, 24,056 patients returned to outpatient clinics within 14 days (the exposure window). Those who received both β-blockers and NDCCBs (n = 302) were excluded, leaving 23,754 patients for analysis. Patients were classified into the β-blocker group (n = 10,638, 44.8%), the NDCCB group, (n = 1,747, 7.4%) and the control group (n = 11,369, 47.9%) based on their outpatient prescription within the exposure window. The β-blockers group of patients had lower overall mortality risks (adjusted hazard ratio [95% confidence interval]: 0.91 [0.83-0.99] versus the NDCCB group; 0.88 [0.84-0.93] versus the control group), but the risk of major adverse cardiac events within 1 year was not statistically different. β-blockers decreased risks of re-hospitalization for COPD and other respiratory diseases by 12-32%. CONCLUSIONS The use of β-blockers after AMI was associated with a reduced mortality risk in patients with COPD. β-blockers did not increase the risk of COPD exacerbations.
Collapse
Affiliation(s)
- Tse-Hsuan Su
- Departments of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Departments of Cardiology, Chang Gung Memorial Hospital Linkou, Taoyuan, Taiwan
| | - Chang-Fu Kuo
- Departments of Rheumatology, Chang Gung Memorial Hospital Linkou, Taoyuan, Taiwan
| | - Pi-Hua Liu
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Ling Chan
- Departments of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Taoyuan, Taiwan
- * E-mail:
| |
Collapse
|
50
|
Nielsen AO, Pedersen L, Sode BF, Dahl M. β-Blocker Therapy and Risk of Chronic Obstructive Pulmonary Disease - A Danish Nationwide Study of 1·3 Million Individuals. EClinicalMedicine 2019; 7:21-26. [PMID: 31193622 PMCID: PMC6537528 DOI: 10.1016/j.eclinm.2019.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/20/2018] [Accepted: 01/15/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The possible association between β-adrenoceptor antagonists (β-blockers) and risk of COPD is controversial. The objective of the present study was to test whether β-blocker use is associated with susceptibility to the disease. METHODS A total of 301,542 new users of β-blockers and 1,000,633 new users of any other antihypertensive drugs aged 30-90 years without any history of COPD hospitalizations were included in the present study and followed in the Danish National Patient Registry for incident admissions for COPD and COPD death between 1995 and 2015. Multiple adjusted cox regression models were used to examine the association between use of β-blockers and COPD hospitalization. Additionally, subgroup analyses based on underlying diseases at baseline or duration of treatment were performed. FINDINGS People treated with β-blockers continuously for more than 6 months had a lower risk of COPD hospitalization during follow-up compared to people treated with any other antihypertensive drugs (adjusted hazard ratio [HRadjusted] 0·80, 95% CI 0·79-0·82). Risk of COPD hospitalization was lowered in the groups treated with β-blockers among patients with ischemic heart disease (0·72, 0·69-0·75), cardiac arrhythmias (0·76, 0·72-0·80), asthma (0·69, 0·61-0·79), hypertension (0·91, 0·86-0·96), and diseases of the pulmonary circulation (pulmonary embolism and cor pulmonale) (0·72, 0·59-0·87). All-cause mortality as well as risk of COPD death during follow-up was lower in the group treated with β-blockers compared to the group treated with any other antihypertensive drugs (0·56, 0·53-0·59). INTERPRETATION Treatment with β-blockers seems to reduce risk of COPD hospitalization and mortality compared to treatment with any other antihypertensive drugs. FUNDING The Danish Council for Independent Research in Denmark (grant no. 4183-00569B), The Research Foundation of Health Science in Region Zealand (grant no. RSSF2017000661 and no. 15-000342), The Research Foundation of Medical Science (A.P. Møller Foundation, grant no. 16-68), The Research Foundation in memory of King Christian 10th (grant no. 142/2017), Aase & Ejnar Danielsen's Research Foundation (grant no. 10-001946), and Lundbeck Foundation (grant no. R252-2017-1690).
Collapse
Affiliation(s)
- Anne Orholm Nielsen
- Department of Clinical Biochemistry, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Birgitte Fischer Sode
- Department of Thoracic Anaesthesiology, the Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Morten Dahl
- Department of Clinical Biochemistry, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
- Corresponding author at: Department of Clinical Biochemistry, Zealand University Hospital, Lykkebækvej 1, DK-4600 Køge, Denmark.
| |
Collapse
|