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β-Blockers in COPD
Egyptian Journal of Chest Diseases and Tuberculosis (2014) 63, 277–278
Egyptian Journal of Chest Diseases and Tuberculosis
Egyptian Journal of Chest Diseases and Tuberculosis www.elsevier.com/locate/ejcdt www.sciencedirect.com
EDITORIAL
b-Blockers in COPD Introduction b-Blockers were frequently withheld in patients with chronic obstructive pulmonary disease (COPD) because of concerns that they might diminish the bronchodilator effect of b2 agonists and aggravate bronchospastic symptoms.1,2 This assumption might have for long deprived many of the COPD patients with substantial cardiovascular comorbidity from the beneficial cardiovascular effect of b-blockers. Although a Cochrane meta-analysis concluded that b-1 selective b blockade was safe,3,4 patients with COPD have half the odds of being treated with b-blockers during acute myocardial infarction (MI) than those without COPD5 and only 35% of patients with congestive heart failure (CHF) and COPD receive b-blocker therapy.6,7 Several observational studies have examined the potential risks and benefits of b-blocker use in COPD. Most studies, to date, have looked at b-blocker use during the usual course of COPD without specifically examining their risk or benefit at the time of an acute exacerbation of COPD (AECOPD).8–11 Physicians may be even more reluctant to continue b-blocker therapy during AE-COPD when a patient’s respiratory status is most tenuous. During an AE-COPD, patients may be particularly vulnerable to develop acute cardiac events12 due to increased use of b2 agonists, tachycardia and hypoxaemia. The addition of a cardioselective b-blocker may have a cardioprotective effect in this population, blunting the cardiac toxicity of the b2 agonists. Stefan et al.13 in his study address the question of the effects of b-blockers given early to patients hospitalised for serious AECOPD who also have ischaemic heart disease or heart failure. The paper reported that the 29% of patients who received b-blockers during the first 2 days of the hospital stay did not have an increased risk of in-hospital mortality, readmission within 30 days, or mechanical ventilation, compared with COPD patients who did not receive b-blockers. The results Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis.
Production and hosting by Elsevier
of this study should be taken with great consideration because it is one of the first studies to highlight the effects of b-blockers during a serious exacerbation requiring hospitalisation. This is a particularly crucial time, as COPD exacerbations are associated with high mortality in the first 1–2 weeks,14 which is likely more if the patients also have cardiovascular comorbidity. Thus, the use or non-use of b-blockers during the first 2 days of hospitalisation may be a marker of specific health status that would dictate continuation or discontinuation of these drugs early in the hospitalisation. This study suggests that bblockers are safe during this particularly high-risk period. Yet, the assumption that a single day or 2 of b-blockers can actually impact on lung function and mortality is still uncertain. Future studies should investigate the effects as a function of duration of exposure, since bronchospasm may be more likely to occur once concomitant therapy changes over the course of hospitalisation, for instance, after a reduction in the dose of bronchodilators.15 Conflict of interest None declared. References [1] J.W. Lammers, H.T. Folgering, C.L. van Herwaarden, Ventilatory effects of long-term treatment with pindolol and metoprolol in hypertensive patients with chronic obstructive lung disease, Br J Clin Pharmacol 20 (1985) 205–210. [2] H.J. van der Woude, J. Zaagsma, D.S. Postma, et al., Detrimental effects of betablockers in COPD: a concern for nonselective beta-blockers, Chest 127 (2005) 818–824. [3] S. Salpeter, T. Ormiston, E. Salpeter, Cardioselective betablockers for chronic obstructive pulmonary disease, Cochrane Database Syst Rev 4 (2005) CD003566. [4] S.R. Salpeter, T.M. Ormiston, E.E. Salpeter, et al., Cardioselective beta-blockers for chronic obstructive pulmonary disease: a meta-analysis, Respir Med 97 (2003) 1094–1101. [5] M.S. Stefan, R.R. Bannuru, D. Lessard, et al., The impact of COPD on management and outcomes of patients hospitalized with acute myocardial infarction: a ten-year retrospective observational study, Chest 141 (2012) 1441–1448.
0422-7638 ª 2013 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. http://dx.doi.org/10.1016/j.ejcdt.2013.12.007
278 [6] S.S. Gottlieb, R.J. McCarter, R.A. Vogel, Effect of betablockade on mortality among high-risk and low-risk patients after myocardial infarction, N Engl J Med 339 (1998) 489–497. [7] M. Egred, S. Shaw, B. Mohammad, et al., Under-use of betablockers in patients with ischaemic heart disease and concomitant chronic obstructive pulmonary disease, QJM 98 (493) (2005) 7. [8] D.H. Au, C.L. Bryson, V.S. Fan, et al., Beta-blockers as singleagent therapy for hypertension and the risk of mortality among patients with chronic obstructive pulmonary disease, Am J Med 117 (2004) 925–931. [9] Y.R. van Gestel, S.E. Hoeks, D.D. Sin, et al., Impact of cardioselective beta-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis, Am J Respir Crit Care Med 178 (2008) 695–700. [10] F.H. Rutten, N.P. Zuithoff, E. Hak, et al., Beta-blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease, Arch Intern Med 170 (2010) 880–887. [11] P.M. Short, S.I. Lipworth, D.H. Elder, et al., Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study, Br Med J 342 (2011) d2549.
Editorial [12] G.C. Donaldson, J.R. Hurst, C.J. Smith, et al., Increased risk of myocardial infarction and stroke following exacerbation of COPD, Chest 137 (2009) 1091–1097. [13] M.S. Stefan, M.B. Rothberg, A. Priya, et al., Association between b-blocker therapy and outcomes in patients hospitalised with acute exacerbations of chronic obstructive lung disease with underlying ischaemic heart disease, heart failure or hypertension, Thorax 67 (2012) 977–984. [14] S. Suissa, S. Dell’Aniello, P. Ernst, Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality, Thorax 67 (2012) 957–963. [15] S. Suissa, P. Ernst, b-Blockers for COPD inpatients, Thorax 67 (2012) 936–937.
Iman Galal Pulmonary Medicine Department, Faculty of Medicine, Ain Shams University, Egypt E-mail address: [email protected] Available online 10 January 2014
Egyptian Journal of Chest Diseases and Tuberculosis
Egyptian Journal of Chest Diseases and Tuberculosis www.elsevier.com/locate/ejcdt www.sciencedirect.com
EDITORIAL
b-Blockers in COPD Introduction b-Blockers were frequently withheld in patients with chronic obstructive pulmonary disease (COPD) because of concerns that they might diminish the bronchodilator effect of b2 agonists and aggravate bronchospastic symptoms.1,2 This assumption might have for long deprived many of the COPD patients with substantial cardiovascular comorbidity from the beneficial cardiovascular effect of b-blockers. Although a Cochrane meta-analysis concluded that b-1 selective b blockade was safe,3,4 patients with COPD have half the odds of being treated with b-blockers during acute myocardial infarction (MI) than those without COPD5 and only 35% of patients with congestive heart failure (CHF) and COPD receive b-blocker therapy.6,7 Several observational studies have examined the potential risks and benefits of b-blocker use in COPD. Most studies, to date, have looked at b-blocker use during the usual course of COPD without specifically examining their risk or benefit at the time of an acute exacerbation of COPD (AECOPD).8–11 Physicians may be even more reluctant to continue b-blocker therapy during AE-COPD when a patient’s respiratory status is most tenuous. During an AE-COPD, patients may be particularly vulnerable to develop acute cardiac events12 due to increased use of b2 agonists, tachycardia and hypoxaemia. The addition of a cardioselective b-blocker may have a cardioprotective effect in this population, blunting the cardiac toxicity of the b2 agonists. Stefan et al.13 in his study address the question of the effects of b-blockers given early to patients hospitalised for serious AECOPD who also have ischaemic heart disease or heart failure. The paper reported that the 29% of patients who received b-blockers during the first 2 days of the hospital stay did not have an increased risk of in-hospital mortality, readmission within 30 days, or mechanical ventilation, compared with COPD patients who did not receive b-blockers. The results Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis.
Production and hosting by Elsevier
of this study should be taken with great consideration because it is one of the first studies to highlight the effects of b-blockers during a serious exacerbation requiring hospitalisation. This is a particularly crucial time, as COPD exacerbations are associated with high mortality in the first 1–2 weeks,14 which is likely more if the patients also have cardiovascular comorbidity. Thus, the use or non-use of b-blockers during the first 2 days of hospitalisation may be a marker of specific health status that would dictate continuation or discontinuation of these drugs early in the hospitalisation. This study suggests that bblockers are safe during this particularly high-risk period. Yet, the assumption that a single day or 2 of b-blockers can actually impact on lung function and mortality is still uncertain. Future studies should investigate the effects as a function of duration of exposure, since bronchospasm may be more likely to occur once concomitant therapy changes over the course of hospitalisation, for instance, after a reduction in the dose of bronchodilators.15 Conflict of interest None declared. References [1] J.W. Lammers, H.T. Folgering, C.L. van Herwaarden, Ventilatory effects of long-term treatment with pindolol and metoprolol in hypertensive patients with chronic obstructive lung disease, Br J Clin Pharmacol 20 (1985) 205–210. [2] H.J. van der Woude, J. Zaagsma, D.S. Postma, et al., Detrimental effects of betablockers in COPD: a concern for nonselective beta-blockers, Chest 127 (2005) 818–824. [3] S. Salpeter, T. Ormiston, E. Salpeter, Cardioselective betablockers for chronic obstructive pulmonary disease, Cochrane Database Syst Rev 4 (2005) CD003566. [4] S.R. Salpeter, T.M. Ormiston, E.E. Salpeter, et al., Cardioselective beta-blockers for chronic obstructive pulmonary disease: a meta-analysis, Respir Med 97 (2003) 1094–1101. [5] M.S. Stefan, R.R. Bannuru, D. Lessard, et al., The impact of COPD on management and outcomes of patients hospitalized with acute myocardial infarction: a ten-year retrospective observational study, Chest 141 (2012) 1441–1448.
0422-7638 ª 2013 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis. http://dx.doi.org/10.1016/j.ejcdt.2013.12.007
278 [6] S.S. Gottlieb, R.J. McCarter, R.A. Vogel, Effect of betablockade on mortality among high-risk and low-risk patients after myocardial infarction, N Engl J Med 339 (1998) 489–497. [7] M. Egred, S. Shaw, B. Mohammad, et al., Under-use of betablockers in patients with ischaemic heart disease and concomitant chronic obstructive pulmonary disease, QJM 98 (493) (2005) 7. [8] D.H. Au, C.L. Bryson, V.S. Fan, et al., Beta-blockers as singleagent therapy for hypertension and the risk of mortality among patients with chronic obstructive pulmonary disease, Am J Med 117 (2004) 925–931. [9] Y.R. van Gestel, S.E. Hoeks, D.D. Sin, et al., Impact of cardioselective beta-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis, Am J Respir Crit Care Med 178 (2008) 695–700. [10] F.H. Rutten, N.P. Zuithoff, E. Hak, et al., Beta-blockers may reduce mortality and risk of exacerbations in patients with chronic obstructive pulmonary disease, Arch Intern Med 170 (2010) 880–887. [11] P.M. Short, S.I. Lipworth, D.H. Elder, et al., Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study, Br Med J 342 (2011) d2549.
Editorial [12] G.C. Donaldson, J.R. Hurst, C.J. Smith, et al., Increased risk of myocardial infarction and stroke following exacerbation of COPD, Chest 137 (2009) 1091–1097. [13] M.S. Stefan, M.B. Rothberg, A. Priya, et al., Association between b-blocker therapy and outcomes in patients hospitalised with acute exacerbations of chronic obstructive lung disease with underlying ischaemic heart disease, heart failure or hypertension, Thorax 67 (2012) 977–984. [14] S. Suissa, S. Dell’Aniello, P. Ernst, Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality, Thorax 67 (2012) 957–963. [15] S. Suissa, P. Ernst, b-Blockers for COPD inpatients, Thorax 67 (2012) 936–937.
Iman Galal Pulmonary Medicine Department, Faculty of Medicine, Ain Shams University, Egypt E-mail address: [email protected] Available online 10 January 2014