Underuse of beta‐blockers by patients with COPD and co‐morbid acute coronary syndrome: A nationwide follow‐up study in New Zealand

Bisoprolol for patients with chronic obstructive pulmonary disease at high risk of exacerbation: the BICS RCT

Background

Observational studies of people with chronic obstructive pulmonary disease using beta-blockers for cardiovascular disease indicate that beta-blocker use is associated with reduced risk of chronic obstructive pulmonary disease exacerbation. However, at the time this study was initiated, there had been no randomised controlled trials confirming or refuting this.

Objective(s)

To determine the clinical and cost-effectiveness of adding bisoprolol (maximal dose 5 mg once daily) to usual chronic obstructive pulmonary disease therapies in patients with chronic obstructive pulmonary disease at high risk of exacerbation.

Design

A multicentre, pragmatic, double-blind, randomised, placebo-controlled clinical trial.

Setting

Seventy-six United Kingdom primary and secondary care sites.

Participants

People aged ≥ 40 years with a diagnosis of at least moderately severe chronic obstructive pulmonary disease with a history of at least two exacerbations in the previous year.

Interventions

Participants were randomised (1 : 1) to receive either bisoprolol or placebo for 1 year. During a 4- to 7-week titration period, the maximum tolerated dose was established (1.25 mg, 2.5 mg, 3.75 mg, 5 mg once daily).

Primary outcome

A number of participant-reported exacerbations during the 1-year treatment period.

Results

In total, 519 participants were recruited and randomised. Four post-randomisation exclusions left 259 in the bisoprolol group and 256 in the placebo group. Treatment groups were balanced at baseline: mean (standard deviation) age 68 (7.9) years; 53% men; mean (standard deviation) pack year smoking history 45 (25.2); mean (standard deviation) 3.5 (1.9) exacerbations in previous year. Primary outcome data were available for 99.8% of participants (bisoprolol 259, placebo 255). The mean (standard deviation) number of exacerbations was 2.03 (1.91) in the bisoprolol group and 2.01 (1.75) in the placebo group (adjusted incidence rate ratio 0.97, 95% confidence interval 0.84 to 1.13), p = 0.72. The number of participants with serious adverse events was similar between the two groups (bisoprolol 37, placebo 36). The total number of adverse reactions was also similar between the two groups. As expected, bisoprolol was associated with a higher proportion of vascular adverse reactions (e.g. hypotension, cold peripheries) than placebo, but was not associated with an excess of other adverse reactions, including those classified as respiratory. Adding bisoprolol resulted in a statistically insignificant trend towards higher costs (£636, 95% confidence interval £118 to £1391) and fewer quality-adjusted life-years (0.035, 95% confidence interval 0.059 to 0.010) compared to placebo.

Limitations

The study findings should be interpreted with caution as the target sample size of 1574 was not achieved because the funder considered the study to be unviable in the COVID-19 pandemic clinical research environment. Although 28% of participants did not initiate bisoprolol/placebo (1.6%) or ceased during the treatment period (26.2%), this is consistent with similar trials in the United Kingdom.

Conclusions

In this underpowered study, the addition of bisoprolol to usual chronic obstructive pulmonary disease treatment did not reduce the likelihood of exacerbations, and bisoprolol cannot be recommended as a treatment for chronic obstructive pulmonary disease.

Future work

To incorporate definitive statements into appropriate clinical guidelines about the safety of bisoprolol for cardiovascular indications in people with chronic obstructive pulmonary disease.

Trial registration

This trial is registered as ISRCTN10497306.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/130/20) and is published in full in Health Technology Assessment; Vol. 29, No. 17. See the NIHR Funding and Awards website for further award information.

Early β-blocker use and in-hospital outcomes in patients with chronic obstructive pulmonary disease hospitalized with acute coronary syndrome: findings from the CCC-ACS project

Background

Patients with chronic obstructive pulmonary disease (COPD) after acute coronary artery syndrome (ACS) are at an increased risk of heart failure and death. However, β-blockers have been underused in this population group due to concerns of adverse reactions.

Objective

This study aims to investigate the β-blocker prescription at admission and its impact on the in-hospital outcomes in patients with COPD after ACS in a Chinese national cohort.

Methods

Among 113,650 patients with ACS enrolled in the national registry of the Improving Care for Cardiovascular Disease in China between November 2014 and July 2019, a total of 1,084 ACS patients with COPD were included in this study. The primary endpoint was in-hospital mortality, and the secondary endpoint was the composite of in-hospital all-cause death and heart failure.

Results

Early oral β-blocker therapy was administered to 49.8% of patients. The Kaplan-Meier analysis showed that the early β-blocker treatment group had lower all-cause mortality (0.9% vs. 2.9%; P < 0.05) and lower combined endpoint event rate (8.2% vs. 12.0%; P < 0.05) compared to the those of the non-early β-blocker treatment group. The analysis of inverse probability of treatment weighting showed that the early β-blocker treatment group was associated with a significantly reduced incidence of all-cause death (risk ratio, 0.332, 0.119-0.923, P = 0.035), heart failure (risk ratio, 0.625, 95% CI 0.414-0.943, P = 0.025), and combined endpoint events (risk ratio: 0.616, 95% CI: 0.418-0.908, P = 0.014). In the subgroup of patients over 70 years of age, the corresponding hazard ratio was 0.268 (95% CI 0.077-0.938) for all-cause mortality and 0.504 (95% CI 0.316-0.805) for combined endpoint events.

Conclusion

β-blockers have been underused in patients with COPD and ACS in China. Early β-blocker therapy is associated with an improvement in in-hospital outcomes in patients with COPD after ACS.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT02306616).

Bisoprolol versus celiprolol on dynamic hyperinflation, cardiopulmonary exercise and domiciliary safety in COPD: a single-centre, randomised, crossover study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is frequently associated with cardiovascular disease. The utility of beta-blockers for treating patients with COPD may be beneficial, but their safety remains uncertain, including worsening of dynamic hyperinflation (DH) during exercise. We hypothesised that among cardioselective beta-blockers celiprolol, due to its partial beta-2 agonist activity, may be safer than bisoprolol on exercise DH.

METHODS

We measured isotime inspiratory capacity (IC) during cycle endurance testing in eleven moderate-severe COPD subjects, alongside other non-invasive cardiopulmonary exercise, bioreactance cardiac output, pulmonary function, biomarkers and daily domiciliary measures. Participants received titrated doses of either bisoprolol (maximim 5 mg) or celiprolol (maximum 400 mg) in randomised crossover fashion, each over 4 weeks.

RESULTS

Clinically relevant DH occurred between resting and exercise isotime IC but showed no significant difference with either beta-blocker compared with post-run-in pooled baseline or between treatments. There were no other significant differences observed for remaining exercise ventilatory; non-invasive cardiac output; resting pulmonary function; beta-2 receptor and cardiac biomarkers; domiciliary pulmonary function, oxygen saturation and symptom outcomes, either between treatments or compared with baseline. No significant adverse effects occurred.

CONCLUSIONS

Significant DH in moderate-severe COPD subjects was no different between bisoprolol or celiprolol or versus baseline. A broad spectrum of other non-invasive cardiopulmonary and domiciliary safety outcomes was equally reassuring. Bronchoprotection with a concomitant long-acting muscarinic antagonist might be an important safety measure in this context.

TRIAL REGISTRATION NUMBER

NCT02380053.

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

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

Certainties fading away: β-blockers do not worsen chronic obstructive pulmonary disease

For many years, β-blockers have been considered contraindicated in patients with heart failure (HF) and in those with bronchial asthma or even chronic obstructive pulmonary disease (COPD) although without clear evidence of asthma. Today, despite overwhelming evidence of the usefulness of β-blockers, especially in HF with reduced left ventricular ejection fraction (HFrEF), and in ischaemic heart disease, some reluctance persists in using these drugs when COPD coexists. Such resistance is due to the fear that a possible worsening of bronchospasm induced by β-blockers could induce negative effects greater than the benefits. The Guidelines of the European Society of Cardiology clearly suggest that: (i) implantation of a cardiac defibrillator (ICD) are not contraindicated in COPD without clear evidence of bronchial asthma; (ii) β-blockers are only ‘relatively’ contraindicated when there is certainty of bronchial asthma with a documented bronchodilator response to the β2 stimulant. Therefore, bronchial asthma is not an absolute contraindication to β-blockers. The cardiologist should not limit the diagnosis of COPD to clinical suspicion, but should rely on a spirometry examination associated with any bronchodilation tests. In any case, selective β1 blockers are preferred, starting at a basic dose, which ensure a better dilator response to bronchodilators and in any case cause less bronchospasm than non-selective β-blockers. Unfortunately, there is still some reluctance to the use of β-blockers in patients with COPD associated with HF, which should be eliminated.

Beta-blockers in chronic obstructive pulmonary disease: the good, the bad and the ugly

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.