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Chiang CH, Jiang YC, Hung WT, Kuo SH, Hsia K, Wang CL, Fu YJ, Lin KC, Lin SC, Cheng CC, Huang WC. Impact of medications on outcomes in patients with acute myocardial infarction and chronic obstructive pulmonary disease: A nationwide cohort study. J Chin Med Assoc 2023; 86:183-190. [PMID: 36652566 DOI: 10.1097/jcma.0000000000000835] [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] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Various inhaled bronchodilators have been associated with cardiovascular safety concerns. This study aimed to investigate the long-term impact of chronic obstructive pulmonary disease (COPD) and the safety of COPD medications in patients after their first acute myocardial infarction (AMI). METHODS This nationwide cohort study was conducted using data from the Taiwan National Health Insurance Research Database. Patients hospitalized between 2000 and 2012 with a primary diagnosis of first AMI were included and divided into three cohorts (AMI, ST-elevation myocardial infarction [STEMI], and non-STEMI [NSTEMI]). Each cohort was propensity score matched (1:1) with patients without COPD. A Cox proportional hazards regression model was used to estimate hazard ratios (HRs) with 95% CIs. RESULTS A total of 186 112 patients with AMI were enrolled, and COPD was diagnosed in 13 065 (7%) patients. Kaplan-Meier curves showed that patients with COPD had a higher mortality risk than those without COPD in all cohorts (AMI, STEMI, and NSTEMI). The HR of mortality in AMI, STEMI, and NSTEMI patients with COPD was 1.12 (95% CI, 1.09-1.14), 1.20 (95% CI, 1.14-1.25), and 1.07 (95% CI, 1.04-1.10), respectively. Short-acting inhaled bronchodilators and corticosteroids increased mortality risk in all three cohorts. However, long-acting inhaled bronchodilators reduced mortality risk in patients with AMI (long-acting beta-agonist [LABA]: HR, 0.87; 95% CI, 0.81-0.94; long-acting muscarinic antagonist [LAMA]: HR, 0.82; 95% CI, 0.69-0.96) and NSTEMI (LABA: HR, 0.89; 95% CI, 0.83-0.97; LAMA: HR, 0.80; 95% CI, 0.68-0.96). CONCLUSION This study demonstrated that AMI patients with COPD had higher mortality rates than those without COPD. Using inhaled short-acting bronchodilators and corticosteroids reduced survival, whereas long-acting bronchodilators provided survival benefits in AMI and NSTEMI patients. Therefore, appropriate COPD medication for acute AMI is crucial.
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Affiliation(s)
- Cheng-Hung Chiang
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan, ROC
| | - You-Cheng Jiang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Wan-Ting Hung
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Shu-Hung Kuo
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Kai Hsia
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chia-Lin Wang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yun-Ju Fu
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Su-Chiang Lin
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Chin-Chang Cheng
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan, ROC
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan, ROC
| | - Wei-Chun Huang
- School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan, ROC
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan, ROC
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
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Amegadzie JE, Gamble JM, Farrell J, Gao Z. Association between Inhaled β2-agonists Initiation and Risk of Major Adverse Cardiovascular Events: A Population-based Nested Case-Control Study. Int J Chron Obstruct Pulmon Dis 2022; 17:1205-1217. [PMID: 35645559 PMCID: PMC9130098 DOI: 10.2147/copd.s358927] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Despite ample evidence underpinning the efficacy of β2-agonists in asthma and chronic obstructive pulmonary disease (COPD), the occurrence of β1- and β2-adrenoceptors in the heart suggests that β2-agonists may have deleterious cardiac effects. We investigated the association between new users of long-or short-acting β2-agonists (LABA or SABA) or ICS (inhaled corticosteroids)/LABA and major adverse cardiovascular events (MACE). Methods A nested case–control analysis was conducted using the UK Clinical Practice Research Datalink of patients with asthma, COPD or asthma–COPD overlap with initial treatment of LABA, SABA, ICS/LABA, ICS, long-or short-acting muscarinic antagonist (LAMA or SAMA) between 01 January 1998 and 31 July 2018. The primary outcome was MACE, defined as the first occurrence of stroke, heart failure, myocardial infarction, arrhythmia, or cardiovascular death. Each case was matched with up to 10 controls on age, sex, date of cohort-entry, and duration of follow-up. The risk of MACE associated with β2-agonists was estimated using conditional logistic regression after controlling for potential confounders. Results The cohort included 180,567 new users of β2-agonists, ICS, SAMA, or LAMA. Among asthmatics, β2-agonists were not associated with the risk of MACE (SABA vs ICS: HR 1.29 [0.96–1.73]; ICS/LABA vs ICS, HR 0.75 [0.33–1.73]). In contrast, among COPD patients, LABA (HR, 2.38 [1.04–5.47]), SABA (HR, 2.02 [1.13–3.59]) and ICS/LABA (HR, 2.08 [1.04–4.16]) users had an increased risk of MACE compared with SAMA users. Among patients with asthma–COPD overlap, SABA (HR, 2.57 [1.26–5.24]) was associated with an increased risk of MACE compared with ICS. Conclusion In conclusion, initiation of LABA, SABA, or ICS/LABA in COPD or SABA in asthma–COPD overlap is associated with increased risk of MACE. No associations were observed among patients with asthma.
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Affiliation(s)
- Joseph Emil Amegadzie
- Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - John-Michael Gamble
- Faculty of Science, School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Jamie Farrell
- Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Zhiwei Gao
- Faculty of Medicine, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
- Correspondence: Zhiwei Gao, Faculty of Medicine, Memorial University, 300 Prince Philip Drive, St. John’s, NL, A1B 3V6, Canada, Tel +17098646523, Email
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Raymakers A, Sin DD, Sadatsafavi M, FitzGerald JM, Marra CA, Lynd LD. Statin use and lung cancer risk in chronic obstructive pulmonary disease patients: a population-based cohort study. Respir Res 2020; 21:118. [PMID: 32429927 PMCID: PMC7236956 DOI: 10.1186/s12931-020-01344-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/26/2020] [Indexed: 01/03/2023] Open
Abstract
Background Patients living with chronic obstructive pulmonary disease (COPD) are at an increased risk of lung cancer. A common comorbidity of COPD is cardiovascular disease; as such, COPD patients often receive statins. This study sought to understand the association between statin exposure and lung cancer risk in a population-based cohort of COPD patients. Methods We identified a population-based cohort of COPD patients based on having filled at least three prescriptions for an anticholinergic or short-acting beta-agonist (SABA). We used an array of methods of defining medication exposure including three conventional methods (ever statin exposure, cumulative duration of use, and cumulative dose) and two novel methods (recency-weighted cumulative duration of use and recency-weighted cumulative dose). To assess residual confounding, a negative control exposure was used to test the validity of our results. All exposure variables were time-dependent. Results The population-based cohort of COPD had 39,879 patients with mean age of 70.6 (SD: 11.2) years and, of which, 53.5% were female. There were 12,469 patients who received at least one statin prescription. Results from the reference case multivariable analysis indicated a reduced risk from statin exposure (HR: 0.85 (95% CI: 0.73–1.00) in COPD patients, but this result not statistically significant. Using the two recency-weighted modelling approaches, statin exposure was associated with a statistically significant reduction in lung cancer risk (recency-weighted cumulative dose, HR: 0.85 (95% CI: 0.77–0.93) and recency-weighted cumulative duration of use, HR: 0.97 (95% CI: 0.96–0.99). Multivariable analysis incorporating the negative control exposure was not statistically significant (HR: 0.89 (95% CI: 0.75–1.10). Conclusions The results of this population-based analysis indicate that statin use in COPD patients may reduce the risk of lung cancer. While the effect was not statistically significantly across all exposure definitions, the overall results support the hypothesis that COPD patients might benefit from statin therapy.
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Affiliation(s)
- Ajn Raymakers
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, British Columbia, V6T1Z3, Canada.,BC Cancer, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - D D Sin
- Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, Canada.,Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - M Sadatsafavi
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, British Columbia, V6T1Z3, Canada
| | - J M FitzGerald
- Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - C A Marra
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - L D Lynd
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, British Columbia, V6T1Z3, Canada. .,Centre for Health Evaluation and Outcome Sciences, Providence Health Research Institute, Vancouver, Canada.
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Melo SMD, Oliveira LAD, Rocha RDA, Wanderley JLF. Bronchodilator test in extreme old age: Adverse effects of short-acting beta-2 adrenergic agonists with clinical repercussion and bronchodilator response. Rev Assoc Med Bras (1992) 2019; 65:1343-1348. [DOI: 10.1590/1806-9282.65.11.1343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/31/2019] [Indexed: 11/22/2022] Open
Abstract
SUMMARY OBJECTIVE: To evaluate chronological age as a limiting factor to perform the bronchodilator test, determine significant adverse effects of short-acting beta 2 agonists with clinical repercussions, and assess bronchodilator response in extreme-old-age patients who undergo the spirometry test. METHODS: This is a cross-sectional and retrospective study. The sample was extracted from the database (spirometer and respiratory questionnaire) of a pulmonary function service. Patients over 90 years old were included in the research, and we evaluated their bronchodilator response and its significant adverse effects that may have clinical repercussions related to the bronchodilator. RESULTS: A sample of 25 patients aged 92.12 ± 2.22 years (95% CI, 91.20 - 93.04), with a minimum age of 90 years and a maximum of 97 years and a predominance of females with 72% (18/25). The bronchodilator test was performed in 84% (21/25) of the patients. The bronchodilator response was evaluated in 19 of the 21 patients (90.47%) who underwent the bronchodilator test. Two tests did not meet the criteria of acceptability and reproducibility. No clinical adverse effects were observed with the bronchodilator medication (salbutamol) during or after the exam. CONCLUSIONS: Chronological age is not a limiting factor for the bronchodilator test, short-acting beta-2 agonists did not present adverse effects with significant clinical repercussion and were useful in the diagnosis and therapeutic guidance of extreme-old-age patients.
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Affiliation(s)
- Saulo Maia d'Avila Melo
- Universidade Tiradentes, Brasil; Universidade Federal de Sergipe, Brasil; Hospital de Urgência de Sergipe, Brasil
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Raymakers AJ, Sadatsafavi M, Sin DD, FitzGerald JM, Marra CA, Lynd LD. Inhaled corticosteroids and the risk of lung cancer in COPD: a population-based cohort study. Eur Respir J 2019; 53:13993003.01257-2018. [DOI: 10.1183/13993003.01257-2018] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 03/13/2019] [Indexed: 01/20/2023]
Abstract
Inhaled corticosteroids (ICSs) are often prescribed in patients with chronic obstructive pulmonary disease (COPD). Their impact on the risk of lung cancer, a leading cause of mortality in COPD patients, remains uncertain.Population-based linked administrative data between the years 1997 and 2007 from the province of British Columbia, Canada, were used to evaluate the association between lung cancer risk and ICS use in COPD patients. COPD was defined on the basis of receipt of three COPD-related prescriptions in subjects ≥50 years of age. Exposure to ICS was incorporated into multivariable Cox regression models using several time-dependent methods (“ever” exposure, cumulative duration of use, cumulative dose, weighted cumulative duration of use and weighted cumulative dose).There were 39 676 patients who met the inclusion criteria. The mean±sd age of the cohort was 70.7±11.1 years and 53% were female. There were 994 (2.5%) cases of lung cancer during follow-up. In the reference case analysis (time-dependent “ever” exposure), ICS exposure was associated with a 30% reduced risk of lung cancer (HR 0.70 (95% CI 0.61–0.80)). ICS exposure was associated with a decrease in the risk of lung cancer diagnosis over all five methods of quantifying exposure.This population-based study suggests that ICS use reduces the risk of lung cancer in COPD patients.
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Rabe KF, Hurst JR, Suissa S. Cardiovascular disease and COPD: dangerous liaisons? Eur Respir Rev 2018; 27:27/149/180057. [PMID: 30282634 DOI: 10.1183/16000617.0057-2018] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently occur together and their coexistence is associated with worse outcomes than either condition alone. Pathophysiological links between COPD and CVD include lung hyperinflation, systemic inflammation and COPD exacerbations. COPD treatments may produce beneficial cardiovascular (CV) effects, such as long-acting bronchodilators, which are associated with improvements in arterial stiffness, pulmonary vasoconstriction, and cardiac function. However, data are limited regarding whether these translate into benefits in CV outcomes. Some studies have suggested that treatment with long-acting β2-agonists and long-acting muscarinic antagonists leads to an increase in the risk of CV events, particularly at treatment initiation, although the safety profile of these agents with prolonged use appears reassuring. Some CV medications may have a beneficial impact on COPD outcomes, but there have been concerns about β-blocker use leading to bronchospasm in COPD, which may result in patients not receiving guideline-recommended treatment. However, there are few data suggesting harm with these agents and patients should not be denied β-blockers if required. Clearer recommendations are necessary regarding the identification and management of comorbid CVD in patients with COPD in order to facilitate early intervention and appropriate treatment.
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Affiliation(s)
- Klaus F Rabe
- Dept of Medicine, University of Kiel, Kiel, Germany .,Lung Clinic Großhansdorf, Airway Research Center North (ARCN), Groβhansdorf, Germany
| | - John R Hurst
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.,Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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Lee CH, Choi S, Jang EJ, Yang HM, Il Yoon H, Kim YJ, Kim J, Yim JJ, Kim DK. Inhaled bronchodilators and acute myocardial infarction: a nested case-control study. Sci Rep 2017; 7:17915. [PMID: 29263396 PMCID: PMC5738390 DOI: 10.1038/s41598-017-17890-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/01/2017] [Indexed: 11/17/2022] Open
Abstract
We investigated the association between the use of inhaled bronchodilators and the risk of AMI. A nested case-control study using the nationwide insurance claims database was conducted. Overall, 11,054 AMI cases and 47,815 matched (up to 1:5) controls were identified from 1,036,119 subjects without acute major cardiovascular events in the past year. Long-acting and short-acting β-agonists (LABAs and SABAs) were associated with increase in the risk of AMI, although an inhaled corticosteroid combined with a long-acting β-agonist was not. Long-acting muscarinic antagonists (LAMAs) in a dry powder inhaler (DPI) were significantly associated with reduced risk of AMI, while LAMAs in a soft mist inhaler (SMI) didn't decrease the risk of it. In hypertensive or diabetic patients, LAMAs in a DPI were associated with reduced risk of AMI, but LABAs were associated with increased risk. Among the β-blocker users, the reduction of AMI risk by LAMAs was the most significant. In conclusions, inhaled β-agonists were associated with increase in the risk of AMI, while LABAs accompanied by ICSs were not associated with increase in the risk of AMI. LAMAs in a DPI use were associated with lower risk of AMI.
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Affiliation(s)
- Chang-Hoon Lee
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Seongmi Choi
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Department of Statistics, College of Natural Sciences, Kyungpook National University, 80 Daehakro, Buk-Gu, Daegu, 41566, Republic of Korea
| | - Eun Jin Jang
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Department of Information Statistics, Colloge of Natural Science, Andong National University, 1375 Gyeongdong-Ro, Andong, 36729, Republic of Korea
| | - Han-Mo Yang
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Ho Il Yoon
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-Ro, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Yun Jung Kim
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
| | - Jimin Kim
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Jae-Joon Yim
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Deog Kyeom Kim
- National Evidence-based Healthcare Collaborating Agency, Namsan Square (Kukdong B/D) 173 Toegye-Ro, Jung-Gu, Seoul, 04554, Republic of Korea.
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-Ro 5-Gil, Dongjak-Gu, Seoul, 07061, Republic of Korea.
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Raymakers AJN, Sadatsafavi M, Sin DD, De Vera MA, Lynd LD. The Impact of Statin Drug Use on All-Cause Mortality in Patients With COPD: A Population-Based Cohort Study. Chest 2017; 152:486-493. [PMID: 28202342 DOI: 10.1016/j.chest.2017.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 12/14/2016] [Accepted: 02/01/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patients with COPD are often prescribed statin drugs due to the increased prevalence of cardiovascular disease. There is considerable debate about the benefits conferred by statin drugs in patients with COPD. This study evaluates the association of statin drug use with all-cause and lung-related mortality in patients with COPD. METHODS This study uses population-based administrative data for the province of British Columbia, Canada. A cohort of patients with COPD was identified based on individual patient prescription records. Statin drug exposure was ascertained in the 1-year period after the COPD diagnosis. The primary and secondary outcomes, all-cause and lung-related mortality, respectively, were evaluated in the 1-year period thereafter using multivariate Cox proportional hazards models and several definitions of medication exposure. RESULTS There were 39,678 patients with COPD that met the study inclusion criteria. Of them, 7,775 (19.6%) had received at least one statin drug dispensed in the exposure ascertainment window. There were 1,446 all-cause deaths recorded in the cohort in the 1-year period after exposure ascertainment. In multivariate analysis, the estimated hazard ratio (HR) for statin drug exposure was 0.79 (95% CI, 0.68-0.92; P = .0016), suggesting a 21% reduction in the risk from statin drug use on all-cause mortality. For lung-related mortality, there was also a considerable reduction in the risk for all-cause mortality from statin drug use (HR, 0.55; 95% CI, 0.32-0.93; P = .0254). These results were robust to different specifications of the exposure ascertainment window. CONCLUSIONS This study shows that statin drug use in a population-based cohort of patients with COPD may confer benefits regarding reduced lung-related and all-cause mortality.
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Affiliation(s)
- Adam J N Raymakers
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Mohsen Sadatsafavi
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada; Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Don D Sin
- Centre for Heart and Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | - Mary A De Vera
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation (CORE), Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada.
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A methodological comparison of two European primary care databases and replication in a US claims database: inhaled long-acting beta-2-agonists and the risk of acute myocardial infarction. Eur J Clin Pharmacol 2016; 72:1105-16. [PMID: 27216032 DOI: 10.1007/s00228-016-2071-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Results from observational studies on inhaled long-acting beta-2-agonists (LABA) and acute myocardial infarction (AMI) risk are conflicting, presumably due to variation in methodology. We aimed to evaluate the impact of applying a common study protocol on consistency of results in three databases. METHODS In the primary analysis, we included patients from two GP databases (Dutch-Mondriaan, UK-CPRD GOLD) with a diagnosis of asthma and/or COPD and at least one inhaled LABA or a "non-LABA inhaled bronchodilator medication" (short-acting beta-2-agonist or short-/long-acting muscarinic antagonist) prescription between 2002 and 2009. A claims database (USA-Clinformatics) was used for replication. LABA use was divided into current, recent (first 91 days following the end of a treatment episode), and past use (after more than 91 days following the end of a treatment episode). Adjusted hazard ratios (AMI-aHR) and 95 % confidence intervals (95 % CI) were estimated using time-dependent multivariable Cox regression models stratified by recorded diagnoses (asthma, COPD, or both asthma and COPD). RESULTS For asthma or COPD patients, no statistically significant AMI-aHRs (age- and sex-adjusted) were found in the primary analysis. For patients with both diagnoses, a decreased AMI-aHR was found for current vs. recent LABA use in the CPRD GOLD (0.78; 95 % CI 0.68-0.90) and in Mondriaan (0.55; 95 % CI 0.28-1.08), too. The replication study yielded similar results. Adjusting for concomitant medication use and comorbidities, in addition to age and sex, had little impact on the results. CONCLUSIONS By using a common protocol, we observed similar results in the primary analysis performed in two GP databases and in the replication study in a claims database. Regarding differences between databases, a common protocol facilitates interpreting results due to minimized methodological variations. However, results of multinational comparative observational studies might be affected by bias not fully addressed by a common protocol.
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[Medical therapy of heart and lung diseases. Effects on the respective other organ]. Herz 2015; 39:15-24. [PMID: 24452761 DOI: 10.1007/s00059-013-4035-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Many patients suffer from both heart and lung diseases. The choice of medical drugs should not only be driven by the clinical and prognostic effects on the target organ but should also be selected based on the effects on the respective other organ. Beta blockers and statins have both beneficial and harmful effects on the respiratory system. Angiotensin-converting enzyme (ACE) inhibitors and amiodarone can cause severe lung damage. Low-dose thiazides and calcium antagonists are first-line medications in hypertensive asthma patients but beta blockers should be avoided. Theophyline should be used with caution in patients with known cardiac disease. Glucocorticosteroids can cause cardiovascular symptoms while the phosphodiesterase inhibitor roflumilast appears to have no relevant cardiovascular side effects. Anticholinergic drugs have both favorable and unfavorable cardiovascular (side) effects. Short-acting beta-2 sympathomimetic drugs (SABA) and macrolides in particular can trigger arrhythmia and some SABAs are associated with a higher incidence of myocardial infarction. Detailed knowledge of the effects of drugs used for the treatment of lung and heart diseases on the respective other organ and the associated complications and long-term effects are essential in providing optimal medical care to the many patients who present with both respiratory and cardiovascular diseases.
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Rottenkolber M, Rottenkolber D, Fischer R, Ibáñez L, Fortuny J, Ballarin E, Sabaté M, Ferrer P, Thürmann P, Hasford J, Schmiedl S. Inhaled beta-2-agonists/muscarinic antagonists and acute myocardial infarction in COPD patients. Respir Med 2014; 108:1075-90. [PMID: 24950946 DOI: 10.1016/j.rmed.2014.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 05/22/2014] [Accepted: 05/27/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Empirical results indicate an increased risk for cardiovascular (CV) adverse drug events (ADE) in chronic obstructive pulmonary disease (COPD) patients treated with beta-2-agonists (B2A) and muscarinic antagonists (MA). A systematic review (including a meta-analysis for drug classes with sufficient sample size) was conducted assessing the association between B2A or MA and acute myocardial infarctions (MI) in COPD patients. METHODS Comprehensive literature search in electronic databases (MEDLINE, Cochrane database) was performed (January 1, 1946-April 1, 2013). Results were presented by narrative synthesis including a comprehensive quality assessment. In the meta-analysis, a random effects model was used for estimating relative risk estimates for acute MI. RESULTS Eight studies (two systematic reviews, two randomized controlled trials, and four observational studies) were comprised. Most studies comparing tiotropium vs. placebo showed a decreased MI risk for tiotropium, whereas for studies with active control arms no clear tendency was revealed. For short-acting B2A, an increased MI risk was shown after first treatment initiation. For all studies, a good quality was found despite some shortcomings in ADE-specific criteria. A meta-analysis could be conducted for tiotropium vs. placebo only, showing a relative risk reduction of MI (0.74 [0.61-0.90]) with no evidence of statistical heterogeneity among the included trials (I(2) = 0%; p = 0.8090). CONCLUSIONS An MI-protective effect of tiotropium compared to placebo was found, which might be attributable to an effective COPD treatment leading to a decrease in COPD-related cardiovascular events. Further studies with effective control arms and minimal CV risk are required determining precisely tiotropium's cardiovascular risk.
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Affiliation(s)
- Marietta Rottenkolber
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians Universitaet Muenchen, Marchioninistr. 15, D-81377 Munich, Germany.
| | - Dominik Rottenkolber
- Institute of Health Economics and Management and Munich Center of Health Sciences, Ludwig-Maximilians-Universitaet Muenchen, Ludwigstr. 28, D-80539 Munich, Germany; Institute of Health Economics and Management, HelmholtzZentrum München - German Research Centre for Environmental Health, Member of the German Center for Lung Research, Ingolstaedter Landstraße 1, D-85764 Neuherberg, Germany
| | - Rainald Fischer
- Medizinische Klinik und Poliklinik V, University Hospital, Ludwig-Maximilians-Universitaet, Ziemssenstr. 1, D-80336 München, Germany
| | - Luisa Ibáñez
- Fundació Institut Català de Farmacologia Servei de Farmacologia, Hospital Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, E-08029 Barcelona, Spain; Departament de Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma de Barcelona, Edifici M, 08193 Bellaterra, Spain
| | - Joan Fortuny
- Novartis Farmaceutica S.A., Apartado 708, E-08080 Barcelona, Spain
| | - Elena Ballarin
- Fundació Institut Català de Farmacologia Servei de Farmacologia, Hospital Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, E-08029 Barcelona, Spain; Departament de Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma de Barcelona, Edifici M, 08193 Bellaterra, Spain
| | - Monica Sabaté
- Fundació Institut Català de Farmacologia Servei de Farmacologia, Hospital Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, E-08029 Barcelona, Spain; Departament de Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma de Barcelona, Edifici M, 08193 Bellaterra, Spain
| | - Pili Ferrer
- Fundació Institut Català de Farmacologia Servei de Farmacologia, Hospital Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, E-08029 Barcelona, Spain
| | - Petra Thürmann
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Heusnerstr. 40, D-42283 Wuppertal, Germany; Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
| | - Joerg Hasford
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians Universitaet Muenchen, Marchioninistr. 15, D-81377 Munich, Germany
| | - Sven Schmiedl
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Heusnerstr. 40, D-42283 Wuppertal, Germany; Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448 Witten, Germany
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Abstract
The goals of management of COPD include reducing exposure to risk factors; improving lung function, exercise tolerance, and quality of life; and decreasing exacerbations and mortality. Pharmacologic treatments, such as inhaled β2-agonists, anticholinergics, and inhaled corticosteroids, are widely used to help achieve these goals. In addition to efficacy, medication safety is an important consideration in selecting COPD treatments. Clinical trials conducted in support of the regulatory review and approval process establish the general efficacy and tolerability of pharmacologic treatments for COPD, and these data are reflected in product labeling. Following approval, further research continues to provide more data with longer follow-up and in broader settings than feasible in clinical trials. These data add to our knowledge of the efficacy of medications. Understanding medication safety requires assessment of the quality and appropriateness of study design, as well as knowledge of study findings, and is of paramount importance in making sound clinical judgments in the treatment of patients with COPD. In recent years, a wealth of data on COPD medications has been published from different sources, including randomized clinical trials, meta-analyses, systematic reviews, and observational studies. This review discusses important considerations in interpreting data from different types of studies, summarizes the tolerability profile of COPD medications established in preapproval studies, and discusses new findings from more recent postapproval data.
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Affiliation(s)
- Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX.
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13
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Zhang J, Zhou JB, Lin XF, Wang Q, Bai CX, Hong QY. Prevalence of undiagnosed and undertreated chronic obstructive pulmonary disease in lung cancer population. Respirology 2013; 18:297-302. [PMID: 23051099 DOI: 10.1111/j.1440-1843.2012.02282.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Chronic obstructive pulmonary disease (COPD) is a risk factor and important coexisting disease for lung cancer; however, the current status of management of COPD in lung cancer patients is not fully described. This study addressed this issue in a general teaching hospital in China. METHODS Medical records of hospitalized lung cancer patients in Zhongshan Hospital, Fudan University, between January 2006 and December 2010 were reviewed. The definition of COPD was according to the spirometric criteria of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) document. The diagnostic rate (COPD recorded as a discharge diagnosis/spirometry-defined percentage) and conformity to GOLD treatment guidelines were investigated. The factors influencing diagnosis were analysed. RESULTS During the study period, the prevalence of spirometry-defined COPD in hospitalized lung cancer patients was 21.6% (705/3263). The overall diagnostic rate of COPD was 7.1%, and the treatment conformity for stable and acute exacerbation of COPD was 27.1% and 46.8%, respectively. Respiratory physicians had a higher diagnostic rate than non-respiratory doctors (34.8% vs 2.9%, P < 0.001) and a better treatment conformity for acute exacerbation of COPD (63.6% vs 37.5%, P = 0.048). Patients with COPD as a discharge diagnosis had more chance to receive guideline-consistent treatment. The diagnostic rate of COPD was higher among patients with a history of smoking, respiratory diseases or symptoms. CONCLUSIONS COPD is substantially underdiagnosed and undertreated in a hospitalized lung cancer population. History of smoking, respiratory diseases and symptoms promotes diagnosis. Education of COPD knowledge among patients and doctors is urgently required in this special population.
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Affiliation(s)
- Jing Zhang
- Departments of Pulmonary Medicine Thoracic Surgery, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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14
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Spencer P, Hanania NA. Optimizing safety of COPD treatments: role of the nurse practitioner. J Multidiscip Healthc 2013; 6:53-63. [PMID: 23459224 PMCID: PMC3583441 DOI: 10.2147/jmdh.s35711] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
As the prevalence of chronic obstructive pulmonary disease (COPD) continues to grow, management of the disease still faces considerable challenges. Despite the existence of effective pharmacological treatments, patient adherence is often poor. Side effects of medications and patients' concerns about potential side effects may contribute to poor adherence. Situated as they are at the frontline of patient care in the clinic, nurse practitioners play an important role in the management of COPD. This review discusses the current literature on medications available for management of COPD, focusing primarily on their safety and tolerability. This information can be particularly important for nurse practitioners, who can be invaluable in identifying side effects, and providing education to patients with COPD on the available treatments and the associated side effects. By helping patients to understand the balance of benefits and risks of treatment, nurse practitioners may be able to help improve adherence and thereby improve patient outcomes.
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Affiliation(s)
- Pamela Spencer
- Palliative Care and Surgery, Veteran’s Affairs Medical Center, Saginaw, MI, USA
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
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15
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Time-dependent propensity score and collider-stratification bias: an example of beta2-agonist use and the risk of coronary heart disease. Eur J Epidemiol 2013; 28:291-9. [DOI: 10.1007/s10654-013-9766-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
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16
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Wilchesky M, Ernst P, Brophy JM, Platt RW, Suissa S. Bronchodilator Use and the Risk of Arrhythmia in COPD. Chest 2012; 142:298-304. [DOI: 10.1378/chest.10-2499] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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17
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Dhand R, Dolovich M, Chipps B, R. Myers T, Restrepo R, Rosen Farrar J. The Role of Nebulized Therapy in the Management of COPD: Evidence and Recommendations. COPD 2012; 9:58-72. [DOI: 10.3109/15412555.2011.630047] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Khorfan FM, Smith P, Watt S, Barber KR. Effects of Nebulized Bronchodilator Therapy on Heart Rate and Arrhythmias in Critically Ill Adult Patients. Chest 2011; 140:1466-1472. [DOI: 10.1378/chest.11-0525] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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19
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Groenwold RHH, de Vries F, de Boer A, Pestman WR, Rutten FH, Hoes AW, Klungel OH. Balance measures for propensity score methods: a clinical example on beta-agonist use and the risk of myocardial infarction. Pharmacoepidemiol Drug Saf 2011; 20:1130-7. [PMID: 21953948 DOI: 10.1002/pds.2251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 08/05/2011] [Accepted: 08/18/2011] [Indexed: 11/11/2022]
Abstract
PURPOSE Propensity score (PS) methods aim to control for confounding by balancing confounders between exposed and unexposed subjects with the same PS. PS balance measures have been compared in simulated data but limited in empirical data. Our objective was to compare balance measures in clinical data and assessed the association between long-acting inhalation beta-agonist (LABA) use and myocardial infarction. METHODS We estimated the relationship between LABA use and myocardial infarction in a cohort of adults with a diagnosis of asthma or chronic obstructive pulmonary disorder from the Utrecht General Practitioner Research Network database. More than two thousand PS models, including information on the observed confounders age, sex, diabetes, cardiovascular disease and chronic obstructive pulmonary disorder status, were applied. The balance of these confounders was assessed using the standardised difference (SD), Kolmogorov-Smirnov (KS) distance and overlapping coefficient. Correlations between these balance measures were calculated. In addition, simulation studies were performed to assess the correlation between balance measures and bias. RESULTS LABA use was not related to myocardial infarction after conditioning on the PS (median heart rate = 1.14, 95%CI = 0.47-2.75). When using the different balance measures for selecting a PS model, similar associations were obtained. In our empirical data, SD and KS distance were highly correlated balance measures (r = 0.92). In simulations, SD, KS distance and overlapping coefficient were similarly correlated to bias (e.g. r = 0.55, r = 0.52 and r = -0.57, respectively, when conditioning on the PS). CONCLUSIONS We recommend using the SD or the KS distance to quantify the balance of confounder distributions when applying PS methods.
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Affiliation(s)
- Rolf H H Groenwold
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands.
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Finkelstein J, Cha E, Scharf SM. Chronic obstructive pulmonary disease as an independent risk factor for cardiovascular morbidity. Int J Chron Obstruct Pulmon Dis 2009; 4:337-49. [PMID: 19802349 PMCID: PMC2754086 DOI: 10.2147/copd.s6400] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Indexed: 01/08/2023] Open
Abstract
RATIONALE Recent studies described association between chronic obstructive pulmonary disease (COPD) and increased risk of cardiovascular diseases (CVD). In their analysis none of these studies accounted for sociodemographic factors, health behaviors, and patient comorbidities simultaneously. OBJECTIVE To study whether COPD diagnosis is an independent risk factor for CVD. METHODS Subjects aged 40 years and older (N = 18,342) from the sample adult file of the 2002 National Health Interview Survey (NHIS) were included in the analysis. Chi-squared tests and odds ratios (OR) were utilized to compare the data. Multiple logistic regression was employed to analyze the association between COPD and CVD with simultaneous control for sociodemographic factors (age, gender, race, marital status, education, income), health behaviors (tobacco use, alcohol consumption, physical activity), and patient comorbidities (diabetes, hypertension, high cholesterol, and obesity). The analysis employed NHIS sampling weights to generate data representative of the entire US population. RESULTS The COPD population had increased prevalence of CVD (56.5% vs 25.6%; P < 0.0001). Adjusted logistic regression showed that COPD patients (N = 958) were at higher risk of having coronary heart disease (OR = 2.0, 95% CI: 1.5-2.5), angina (OR = 2.1, 95% CI: 1.6-2.7), myocardial infarction (OR = 2.2, 95% CI: 1.7-2.8), stroke (OR = 1.5, 95% CI: 1.1-2.1), congestive heart failure (OR = 3.9, 95% CI: 2.8-5.5), poor circulation in lower extremities (OR = 2.5, 95% CI: 2.0-3.0), and arrhythmia (OR = 2.4, 95% CI: 2.0-2.8). Overall, the presence of COPD increased the odds of having CVD by a factor of 2.7 (95% CI: 2.3-3.2). CONCLUSIONS These findings support the conclusion that COPD is an independent risk factor for CVD.
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Affiliation(s)
- Joseph Finkelstein
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD 21205, USA.
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22
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The pattern of risk of myocardial infarction in patients taking asthma medication: a study with the General Practice Research Database. J Hypertens 2009; 27:1485-92. [PMID: 19491706 DOI: 10.1097/hjh.0b013e32832af68d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To describe the patterns of risks of acute myocardial infarction (MI) during exposure to long-acting beta2-agonists (LABA). METHODS The study population consisted of patients aged 18+ years prescribed LABA or short-acting beta2-agonists (SABA) in the UK General Practice Research Database (GPRD). The outcomes included acute MI as recorded in GPRD and hospitalization for acute MI as obtained from the national registry of hospital admissions in England. The patterns of the hazard rates over time (i.e. absolute risks) were evaluated. RESULTS The study population included 507,966 patients, who received a total of 5.5 million inhaled SABA, 4.0 million inhaled corticosteroids (ICS) and 1.3 million LABA prescriptions. In patients who recently started asthma medication, there were substantial changes in the hazard rates of MI over time: hazard rates were increased shortly following the prescription and then decreased. The hazard rates of MI in GPRD and of MI hospitalizations were proportional over time between inhaled SABA, LABA and ICS. Heavy long-term users (13+ Rx of the same asthma drug in the 1 year before) had increased risks of MI both with inhaled SABA and ICS. The relative rate in the heavy long-term users was 1.6 with inhaled SABA, 1.1 with LABA and 1.7 with ICS. The pattern of risk was similar between LABA with and without concomitant ICS use. CONCLUSION The patterns of risks of MI were broadly similar between inhaled SABA, LABA and ICS, suggesting that there were no major differences between these drugs.
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Appleton SL, Ruffin RE, Wilson DH, Taylor AW, Adams RJ. Cardiovascular disease risk associated with asthma and respiratory morbidity might be mediated by short-acting beta2-agonists. J Allergy Clin Immunol 2009; 123:124-130.e1. [PMID: 19130933 DOI: 10.1016/j.jaci.2008.10.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Revised: 10/16/2008] [Accepted: 10/21/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies examining the asthma-related risks of cardiovascular disease (CVD) events have generally used selected samples or did not control for the effects of beta(2)-agonist use, itself associated with CVD events. OBJECTIVES We assessed the relationship between incident CVD/stroke and asthma and the effect of atopy while controlling for beta(2)-agonist use in a representative adult population cohort free of CVD at baseline. METHODS The North West Adelaide Health Study (stage 1, n = 3812; stage 2, n = 3113) assessed spirometry, anthropometry, atopy, blood pressure, and lipid levels. Questionnaires assessed doctor-diagnosed asthma and CVD (myocardial infarction and angina)/stroke, smoking status, and demographics. Asthma was defined by self-report or FEV(1) reversibility. Current short- and long-acting beta(2)-agonist use was identified at follow-up. RESULTS Results are expressed as odds ratios (ORs) and 95% CIs. By using multivariable logistic regression, after adjustment for risk factors, in female subjects incident CVD/stroke events were associated with asthma (OR, 3.24; 95% CI, 1.55-6.78), with no effect modification by atopy (P for interaction = .61), and with as-required short-acting beta(2)-agonist use (OR, 2.66; 95% CI, 1.06-6.61). In male subjects events were associated with daily cough/sputum (OR, 1.92; 95% CI, 1.05-3.50) and FEV(1) of less than 80% of predicted value but an FEV(1)/forced vital capacity ratio of greater than 0.70 (OR, 2.15; 95% CI, 0.91-5.09; P = .08). Although few CVD/stroke events occurred in male subjects with asthma, a significant interaction with atopic status was found (P = .05). CONCLUSIONS Studies are required to elucidate how asthma exposes older women to excess macrovascular risk and prospectively determine the short-acting beta(2)-agonist-related risk in persons without existing CVD. CVD risk in relation to atopic status of asthma also requires further investigation.
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Affiliation(s)
- Sarah L Appleton
- The Health Observatory, Department of Medicine, University of Adelaide, The Queen Elizabeth Hospital Campus, Woodville, Australia.
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Macnee W, Maclay J, McAllister D. Cardiovascular injury and repair in chronic obstructive pulmonary disease. PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY 2008; 5:824-33. [PMID: 19017737 PMCID: PMC2643206 DOI: 10.1513/pats.200807-071th] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Accepted: 08/25/2008] [Indexed: 01/22/2023]
Abstract
Cardiovascular disease represents a considerable burden in terms of both morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD). For 20 years, forced expiratory volume in 1 second (FEV(1)) has been an established predictor of cardiovascular mortality among smokers, never-smokers, and patients with COPD. We review evidence for increased cardiovascular risk in COPD. In addition, we assess the emerging evidence which suggests that hypoxia, systemic inflammation, and oxidative stress in patients with COPD may cause cardiovascular disease. We also discuss alternative hypotheses that the endothelium and connective tissues in the arteries and lungs of patients with COPD and cardiovascular disease have a shared susceptibility to these factors.
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Affiliation(s)
- William Macnee
- ELEGI Colt Research Labs, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, EH16 4TJ, Scotland, UK.
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25
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Tacoy G, Kocaman SA, Balcioğlu S, Tanindi A, Ozdemir M, Cemri M, Cengel A. Coronary vasospastic crisis leading to cardiogenic shock and recurrent ventricular fibrillation in a patient with long-standing asthma. J Cardiol 2008; 52:300-4. [PMID: 19027611 DOI: 10.1016/j.jjcc.2008.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 05/26/2008] [Accepted: 05/28/2008] [Indexed: 11/19/2022]
Abstract
Acute myocardial infarction in patients with normal coronary arteries is a therapeutic dilemma. Coronary artery vasospasm and thrombosis are the most commonly encountered clinic problems and appear in localized coronary segments. The incidence of cardiovascular disease is increased in asthmatic patients. ß(2)-Adrenergic agonists use is associated with increased cardiovascular events. Although myocardial ischemia during asthma has been described in literature, acute myocardial infarction and ventricular fibrillation with normal coronary arteries in patients with asthma bronchiale is a rare entity. Our patient with long-standing asthma bronchiale presented with cardiogenic shock whose coronary angiography revealed multivessel disease and undergone primary percutaneous coronary intervention. Due to ongoing chest pain and hemodynamic instability; an early bypass surgery was planned. A control angiogram was performed before surgery. After intracoronary nitrate administration all narrowings in coronary vasculature disappeared. Symptom relief and clinical improvement was achieved with nitrate and calcium channel blockers later. After 2 months she was readmitted with cardiac arrest due to recurrent ventricular fibrillation and intracardiac defibrillator implantation was performed.
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Affiliation(s)
- Gulten Tacoy
- Gazi University, Faculty of Medicine, Cardiology Department, Besevler 06500, Ankara, Turkey.
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Impact of cancers and cardiovascular diseases in chronic obstructive pulmonary disease. Curr Opin Pulm Med 2008; 14:115-21. [DOI: 10.1097/mcp.0b013e3282f45ffb] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Vries F, Pouwels S, Bracke M, Lammers JW, Klungel O, Leufkens H, van Staa T. Use of beta2 agonists and risk of acute myocardial infarction in patients with hypertension. Br J Clin Pharmacol 2008; 65:580-6. [PMID: 18279472 DOI: 10.1111/j.1365-2125.2007.03077.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT * Use of beta(2) agonists has been associated with tachycardia, an abnormal ECG and atrial fibrillation. * Previous observational studies of the association between use of beta(2) agonists and the risk of acute myocardial infarction (MI) have demonstrated conflicting results. * Instead of a causal effect, the positive association between beta(2) agonist use and MI may be explained by latent ischaemic heart disease, which has symptoms that appear similar to respiratory complaints in chronic obstructive pulmonary disease. WHAT THIS STUDY ADDS * The majority of beta(2) agonist users in our study population did not have an increased risk of nonfatal acute MI. * Only patients with ischaemic heart disease and who had recently started beta(2) agonists had an increased risk of acute MI. * It is likely that this increased risk was related to latent cardiovascular disease rather than direct effects of beta(2) agonists. AIM Observational retrospective studies of the association between use of beta(2) agonists and the risk of acute myocardial infarction (MI) have demonstrated conflicting results, particularly among first-time users. The aim of this study was to examine the association between beta(2) agonist use and first nonfatal acute MI. METHODS We conducted a case-control study (2476 cases) nested in a cohort of antihypertensive drug users in the Dutch PHARMO RLS database. PHARMO RLS consists of drug dispensing linked to the national hospitalizations register. Each case of nonfatal acute MI was matched with up to 12 control patients by gender, age and region. Drug and disease history and the severity of the underlying respiratory disease were adjusted for. RESULTS Risk of acute MI was increased in current beta(2) agonist users [crude odds ratio (OR) 1.36, 95% confidence interval (CI) 1.15, 1.61]. However, this excess risk was reduced after adjustment for severity of asthma and chronic obstructive pulmonary disease (adjusted OR 1.18, 95% CI 0.93, 1.49). The risk was highest in patients with ischaemic heart disease and low cumulative dose of beta(2) agonists (adjusted OR 2.47, 95% CI 1.60, 3.82). CONCLUSION Most users of beta(2) agonists did not have an increased risk of acute MI. Only patients with ischaemic heart disease with low cumulative exposure to beta(2) agonists had an increased risk of acute MI. It is likely that this increased risk was related to latent cardiovascular disease rather than to the direct effects of beta(2) agonists.
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Affiliation(s)
- Frank de Vries
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology and Pharmacotherapy, Universiteit Utrecht, Utrecht, The Netherlands.
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Parker H, Brenya R, Zarich S, Manthous CA. β-agonists for patients with chronic obstructive pulmonary disease and heart disease? Am J Emerg Med 2008; 26:104-5. [DOI: 10.1016/j.ajem.2007.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Accepted: 07/19/2007] [Indexed: 10/22/2022] Open
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Macie C, Wooldrage K, Manfreda J, Anthonisen N. Cardiovascular morbidity and the use of inhaled bronchodilators. Int J Chron Obstruct Pulmon Dis 2008; 3:163-9. [PMID: 18488440 PMCID: PMC2528211 DOI: 10.2147/copd.s1516] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We used the Manitoba Health database to examine the relationship between use of inhaled respiratory drugs in people with chronic obstructive respiratory diseases and cardiovascular hospitalizations from 1996 through 2000. The drugs examined were beta agonists [BA], ipratropium bromide IB, and inhaled steroids (ICS). End points were first hospitalizations for supraventricular tachycardia, myocardial infarction, heart failure or stroke. A nested case control analysis was employed comparing people with and without cardiovascular events. Cases and controls were matched for gender and age, and conditional logistic regression was used in multivariate analysis considering other respiratory drugs, respiratory diagnosis and visit frequency, non-respiratory, non-cardiac comorbidities, and receipt of drugs for cardiovascular disease. In univariate analyses, BA, IB and ICS were all associated with hospitalizations for cardiovascular disease, but in multivariate analyses ICS did not increase risk while both BA and IB did. There were interactions between respiratory and cardiac drugs receipt in that bronchodilator associated risks were higher in people not taking cardiac drugs; this was especially true for stroke. There were strong interactions with specific cardiac drugs; for example, both BA and IB substantially increased the risk of supraventricular tachycardia in patients not anti-arryhthmic agents, but not in the presence of such agents. We conclude that bronchodilator therapy for chronic obstructive diseases is associated with increased cardiovascular risk, especially in patients without previous cardiovascular diagnoses, and that this is unlikely due to the severity of the respiratory disease, since risk was not increased with ICS.
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Affiliation(s)
- Christine Macie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Kleerup E. Quality indicators for the care of chronic obstructive pulmonary disease in vulnerable elders. J Am Geriatr Soc 2007; 55 Suppl 2:S270-6. [PMID: 17910547 DOI: 10.1111/j.1532-5415.2007.01332.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Eric Kleerup
- Division of Pulmonary, Critical Care Medicine and Hospitalists, David Geffen School of Medicine at the University of California, Los Angeles, CA 90095, USA.
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Joos GF. Are β2-Agonists Safe in Patients with Acute Exacerbations of COPD? Am J Respir Crit Care Med 2007; 176:322-3. [PMID: 17675449 DOI: 10.1164/rccm.200704-643ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Meinke L, Chitkara R, Krishna G. Advances in the management of chronic obstructive pulmonary disease. Expert Opin Pharmacother 2007; 8:23-37. [PMID: 17163804 DOI: 10.1517/14656566.8.1.23] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death, seems to be increasing in worldwide prevalence, and carries with it a significant health and economic burden. Smoking cessation is the only available intervention proven to halt disease progression. The authors discuss the role of the newly approved agent, varenicline, in promotion of smoking cessation. The remainder of presently available therapies treat the symptoms of COPD, but do not impact progression of disease. As the understanding of the pathogenesis of COPD improves, new targets for therapies are emerging. Given the large number of potential targets and the results of recent studies, it seems unlikely that a single new agent will result in a cure. Rather, management of COPD should involve a multi-pronged approach including smoking cessation, bronchodilators, treatment of infection, and eventual targeting of inflammatory pathways and genetic predispositions. In this article, the authors discuss presently available therapies as well as agents under development.
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Affiliation(s)
- Laura Meinke
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
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Abstract
Short-acting beta(2)-agonists are the mainstay of therapy for acute bronchospasm associated with asthma and chronic obstructive pulmonary disease, whereas long-acting beta(2)-agonists are used in maintaining disease control in these respiratory disorders. This review describes and compares the pharmacology of the beta(2)-agonists and explains how these differences translate into differences in efficacy and beta(2)-adrenergic-mediated adverse effects. Questions commonly asked by clinicians regarding the efficacy and safety of short- and long-acting beta(2)-agonists include issues about cardiovascular effects, tolerance to their bronchodilator and bronchoprotective effects, blunting of albuterol response by long-acting beta(2)-agonists, potential masking of worsening asthma control, and the role of long-acting beta(2)-agonists as adjunctive therapy with inhaled corticosteroids in maintaining asthma control. Pharmacogenetics may play a role in determining which patients may be at risk for a reduced response to a beta(2)-agonist. The continued use of racemic albuterol, which contains a mixture of R-albuterol and S-albuterol, has been questioned because of data from preclinical and clinical studies suggesting that S-albuterol causes proinflammatory effects and may increase bronchial hyperreactivity. The preclinical and clinical effects of these two stereoisomers are reviewed. Data describing the efficacy and safety of levalbuterol (R-albuterol) and racemic albuterol are presented.
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Affiliation(s)
- H William Kelly
- Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico 87131, USA.
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Abstract
A patient with a painless, extensive anterolateral myocardial infarct, which occurred during a prolonged bout of refractory asthma, is presented. Cardiac catheterization revealed a large akinetic area involving the septum and anterolateral walls and completely normal coronary arteries. The etiology of the infarct was believed to be intense coronary vasospasm occurring during the lengthy period of status asthmaticus.
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Affiliation(s)
- Basil M RuDusky
- Northeast Cardiovascular Clinic and Research Center, Wilkes-Barre, PA, USA
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Lefebvre G, Angers JF, Blais L. Estimation of time-dependent rate ratios in case-control studies: comparison of two approaches for exposure assessment. Pharmacoepidemiol Drug Saf 2006; 15:304-16. [PMID: 16389656 DOI: 10.1002/pds.1201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE In pharmacoepidemiology, it is well recognized that the rate of adverse events may vary as a function of the cumulative duration of the drug exposure and/or the time since the end of the exposure. In case-control studies, two different approaches have been used to estimate temporal effects of drug exposure: the time-windows (T-Ws) approach and the duration-specific (D-S) approach. We decided to conduct a simulation study to compare the two approaches when the rate ratios (RRs) vary as a function of the cumulative duration of exposure and/or the time since the end of exposure. METHODS We generated three cohorts of 500,000 individuals in which the rate of the event was varying as a function of the cumulative duration of exposure and the time since the end of exposure. For each cohort, a nested case-control analysis was performed using both the D-S and the T-Ws approaches. In the T-Ws approach, a RR is estimated within specific periods of time prior to the outcome, while a RR is estimated within periods of cumulative duration of exposure and time since the end of exposure in the D-S approach. RESULTS We found that the RRs obtained from the D-S approach exactly corresponded to the RRs obtained from the cohort analyses, while the RRs obtained from the T-Ws approach generally not. RRs obtained from the T-Ws approach were difficult to interpret in terms of the effect of the duration and timing of the exposure. CONCLUSION The D-S approach should be used to investigate the duration-related effects of exposure in case-control studies.
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Affiliation(s)
- Geneviève Lefebvre
- Mathematics and Statistics Department, Université de Montréal, Montreal, Canada
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Use of oral corticosteroids and the risk of acute myocardial infarction. Atherosclerosis 2006; 192:376-83. [PMID: 16787647 DOI: 10.1016/j.atherosclerosis.2006.05.019] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 05/05/2006] [Accepted: 05/09/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION A few epidemiological studies suggested an increased coronary heart disease (CHD) risk with high doses of oral corticosteroids. METHODS We performed a cohort study with nested case-control analysis to estimate the risk of acute myocardial infarction (AMI) associated with the use of oral corticosteroids by dose and duration. We followed-up 404,183 persons, 50-84 years old, without cancer from the general UK population. After validation of a random sample (confirmation rate of 96%), we included 4795 hospitalised cases of AMI or CHD deaths. We randomly sampled 20,000 controls, frequency matched by sex, age and calendar year. Relative risks were estimated using unconditional logistic regression. RESULTS The adjusted OR for AMI in current users of oral corticosteroids compared to non-users was 1.42 (95% CI: 1.17-1.72). The risk during the first 30 days of use (OR=2.24; 95% CI: 1.56-3.20) was greater than with longer duration (OR=1.22; 95% CI 0.98-1.52). The risk was more pronounced (OR=2.15; 95% CI 1.45-3.14) among users of prednisolone equivalent doses >10mg/day. The dose effect was observed both among patients with and without CHD or COPD/asthma. CONCLUSION These results suggest a small increased risk of AMI with oral corticosteroid use with a greater risk observed among users of high corticosteroid dose.
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Abstract
A review of the most relevant evidence based therapeutic options currently available for the management of exacerbations of COPD.
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Affiliation(s)
- R Rodríguez-Roisin
- Servei de Pneumologia, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain.
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Mancini GBJ, Etminan M, Zhang B, Levesque LE, FitzGerald JM, Brophy JM. Reduction of morbidity and mortality by statins, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers in patients with chronic obstructive pulmonary disease. J Am Coll Cardiol 2006; 47:2554-60. [PMID: 16781387 DOI: 10.1016/j.jacc.2006.04.039] [Citation(s) in RCA: 238] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Revised: 03/21/2006] [Accepted: 04/04/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The purpose of this study was to determine if statins (hydroxymethylglutaryl CoA reductase inhibitors [HMG-CoA]), angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs) reduce cardiovascular (CV) events and pulmonary morbidity in chronic obstructive pulmonary disease (COPD) patients. BACKGROUND Few current COPD therapies alter prognosis. Although statins, ACE inhibitors, and ARBs improve outcomes in CV populations, their benefits in COPD patients both with and without concomitant heart disease has not previously been studied. METHODS A time-matched nested case-control study of two population-based retrospective cohorts was undertaken: 1) COPD patients having undergone coronary revascularization (high CV risk cohort); and 2) COPD patients without previous myocardial infarction (MI) and newly treated with nonsteroidal anti-inflammatory drugs (low CV risk cohort). Prespecified outcomes were COPD hospitalization, MI, and total mortality. RESULTS These drugs reduced both CV and pulmonary outcomes, with the largest benefits occurring with the combination of statins and either ACE inhibitors or ARBs. This combination was associated with a reduction in COPD hospitalization (risk ratio [RR] 0.66, 95% confidence interval [CI] 0.51 to 0.85) and total mortality (RR 0.42, 95% CI 0.33 to 0.52) not only in the high CV risk cohort but also in the low CV risk cohort (RR 0.77, 95% CI 0.67 to 0.87, and RR 0.36, 95% CI 0.28 to 0.45, respectively). The combination also reduced MI in the high CV risk cohort (RR 0.39, 95% CI 0.31 to 0.49). Benefits were similar when steroid users were included. CONCLUSIONS These agents may have dual cardiopulmonary protective properties, thereby substantially altering prognosis of patients with COPD. These findings need confirmation in randomized clinical trials.
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Affiliation(s)
- G B John Mancini
- Division of Cardiology, Vancouver Hospital, Jack Bell Research Centre, University of British Columbia, Vancouver, British Columbia, Canada.
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Cazzola M, Matera MG, Donner CF. Inhaled beta2-adrenoceptor agonists: cardiovascular safety in patients with obstructive lung disease. Drugs 2006; 65:1595-610. [PMID: 16060696 DOI: 10.2165/00003495-200565120-00001] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Although large surveys have documented the favourable safety profile of beta(2)-adrenoceptor agonists (beta(2)-agonists) and, above all, that of the long-acting agents, the presence in the literature of reports of adverse cardiovascular events in patients with obstructive airway disease must induce physicians to consider this eventuality. The coexistence of beta(1)- and beta(2)-adrenoceptors in the heart clearly indicates that beta(2)-agonists do have some effect on the heart, even when they are highly selective. It should also be taken into account that the beta(2)-agonists utilised in clinical practice have differing selectivities and potencies. beta(2)-agonist use has, in effect, been associated with an increased risk of myocardial infarction, congestive heart failure, cardiac arrest and sudden cardiac death. Moreover, patients who have either asthma or chronic obstructive pulmonary disease may be at increased risk of cardiovascular complications because these diseases amplify the impact of these agents on the heart and, unfortunately, are a confounding factor when the impact of beta(2)-agonists on the heart is evaluated. Whatever the case may be, this effect is of particular concern for those patients with underlying cardiac conditions. Therefore, beta(2)-agonists must always be used with caution in patients with cardiopathies because these agents may precipitate the concomitant cardiac disease.
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Affiliation(s)
- Mario Cazzola
- Unit of Pneumology and Allergology, Department of Respiratory Medicine, Cardarelli Hospital, Naples, Italy
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Sidney S, Sorel M, Quesenberry CP, DeLuise C, Lanes S, Eisner MD. COPD and incident cardiovascular disease hospitalizations and mortality: Kaiser Permanente Medical Care Program. Chest 2005; 128:2068-75. [PMID: 16236856 DOI: 10.1378/chest.128.4.2068] [Citation(s) in RCA: 341] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
STUDY OBJECTIVES To determine the relationship between diagnosed and treated COPD and the incidence of cardiovascular disease (CVD) hospitalization and mortality. DESIGN Retrospective matched cohort study. SETTING Northern California Kaiser Permanente Medical Care Program (KPNC), a comprehensive prepaid integrated health-care system. PATIENTS OR PARTICIPANTS Case patients (n = 45,966) were all KPNC members with COPD who were identified during a 4-year period from January 1996 through December 1999. An equal number of control subjects without COPD were selected from KPNC membership and were matched for gender, year of birth, and length of KPNC membership. MEASUREMENTS AND RESULTS Follow-up conducted for hospitalization and mortality from CVD end points through December 31, 2000. CVD study end points included cardiac arrhythmias, angina pectoris, acute myocardial infarction, congestive heart failure (CHF), stroke, pulmonary embolism, all of the aforementioned study end points combined, other CVD, and all CVD end points. The mean follow-up time was 2.75 years for case patients and 2.99 years for control subjects. The risk of hospitalization was higher in COPD case patients than in control subjects for all CVD hospitalization and mortality end points. The relative risk (RR) for hospitalization for the composite measure of all study end points was 2.09 (95% confidence interval [CI], 1.99 to 2.20) after adjustment for gender, preexisting CVD study end points, hypertension, hyperlipidemia, and diabetes, and ranged from 1.33 (stroke) to 3.75 (CHF). The adjusted RR for mortality for the composite measure of all study end points was 1.68 (95% CI, 1.50 to 1.88), ranging from 1.25 (stroke) to 3.53 (CHF). Younger patients (ie, age < 65 years) and female patients had higher risks than older and male participants. CONCLUSIONS COPD was a predictor of CVD hospitalization and mortality over an average follow-up time of nearly 3 years. The finding of a stronger relationship of COPD to CVD outcomes in patients < 65 years of age suggests that CVD risk should be monitored and treated with particular care in younger adults with COPD.
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Affiliation(s)
- Stephen Sidney
- Division of Research, Kaiser Permanente Medical Care Program, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA.
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Huerta C, Lanes SF, García Rodríguez LA. Respiratory medications and the risk of cardiac arrhythmias. Epidemiology 2005; 16:360-6. [PMID: 15824553 DOI: 10.1097/01.ede.0000158743.90664.a7] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Medications used to treat respiratory diseases include beta-adrenoceptors, antimuscarinics, inhaled and oral corticosteroids, and theophyllines. Most of these drugs have been associated indirectly with cardiac rhythm disorders, but epidemiologic evidence is limited. METHODS To evaluate the association between respiratory drugs and the occurrence of rhythm disorders among patients with asthma and those with chronic obstructive pulmonary disease, we conducted a case-control study nested in a population-based cohort of individuals 10-79 years of age and registered in the U.K. General Practice Research Database after 1 January 1994. The analysis included 710 confirmed cases and 5000 controls frequency-matched to cases by age (interval of 1 year) and sex. RESULTS No increased risk of arrhythmias overall was found among users of inhaled steroids (relative risk = 1.0; 95% confidence interval = 0.8-1.3). Short-term use of theophylline was weakly associated with arrhythmia (1.8; 1.0-3.3). An increased risk was found among users of oral steroids, and the relative risk was greater at the beginning of therapy (2.6; 2.0-3.5). The risk of atrial fibrillation was increased, especially for short-term use of oral steroids (2.7; 1.9-3.8), and a weak association was seen for theophyllines, especially short-term use (1.8; 0.9-3.7). Supraventricular tachycardia was associated with long-term use of oral steroids (2.1; 0.8-5.7), long-term use of antimuscarinics (1.7; 0.7-4.1), and short-term use of theophylline (4.0; 0.9-18.1). Ventricular arrhythmias were associated with oral steroids (3.2; 0.8-13.3) and beta-adrenoceptors (7.1; 0.8-65.9). CONCLUSIONS Oral steroids and theophylline were the therapeutic groups associated with risk of developing atrial fibrillation, especially with new courses of therapy. Results from this study also are consistent with certain suspected dysrhythmic effects of theophyllines, with supraventricular tachycardia associated with antimuscarinics, and with ventricular arrhythmias associated with beta-adrenoceptors.
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Affiliation(s)
- Consuelo Huerta
- Centro Español de Investigación Farmacoepidemiológica, Almirante 28, 2o, 28004 Madrid, Spain.
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Affiliation(s)
- Rachel Booker
- COPD module leader at the National Respiratory Training Centre
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Kelly HW. What is new with the beta2-agonists: issues in the management of asthma. Ann Pharmacother 2005; 39:931-8. [PMID: 15811904 DOI: 10.1345/aph.1e611] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the more recent literature addressing the issue of whether beta2-agonists can worsen asthma and/or increase the risk of severe exacerbations and death from asthma. DATA SOURCES PubMed was searched (2001-December 2004), along with the Food and Drug Administration and Cochrane Library Web sites. In addition, the bibliographies of recent reviews of the subject were assessed. STUDY SELECTION AND DATA EXTRACTION Randomized clinical trials, retrospective and prospective cohort studies, and meta-analyses published in the past 3 years were reviewed. Studies assessing the potential for beta2-agonists to worsen outcomes in asthma as well as long-term studies assessing asthma outcomes that included an arm with regular administration of short- or long-acting inhaled beta2-agonists (LABAs) were selected. Worsening asthma was defined as a decline in lung function, an increase in bronchial hyperresponsiveness, exacerbations, or death. Studies older than 3 years selected from the bibliographies of the primary articles that addressed background perspective were also included where appropriate. DATA SYNTHESIS The studies fell into 3 primary categories with some overlap: those assessing toxicity of the S-enantiomer of albuterol, those evaluating the risk of specific genotypes regarding worsening asthma, and those assessing asthma outcomes with LABA therapy. CONCLUSIONS The current data on the use of beta2-agonists continue to support the national and international guidelines for the treatment of asthma. That is, short-acting inhaled beta2-agonists should only be used as needed for symptoms and prevention of exercise-induced bronchospasm, and LABAs should only be used regularly as adjunctive therapy with inhaled corticosteroids in patients whose asthma is not controlled with low to medium doses of the inhaled corticosteroid.
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Affiliation(s)
- H William Kelly
- Department of Pediatrics, Pediatrics/Pulmonary, MSC10-5590, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
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García Río F, Ramírez Prieto M, Alonso Fernández A. Broncodilatadores de acción corta: ¿qué lugar les reservamos? Arch Bronconeumol 2005. [DOI: 10.1016/s0300-2896(05)70734-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hockman RH. Pharmacologic therapy for acute exacerbations of chronic obstructive pulmonary disease: a review. Crit Care Nurs Clin North Am 2004; 16:293-310, vii. [PMID: 15358379 DOI: 10.1016/j.ccell.2004.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article reviews available data on the drug therapy armamentarium for the acute exacerbation of chronic obstructive pulmonary disease (COPD). Summaries of studies and therapeutic issues for bronchodilators, antibiotic therapy, corticosteroid use, and a few miscellaneous agents are presented. Many controversies exist in the criteria defining the acute exacerbation, in defining appropriate outcome parameters for assessment, and, consequently, in developing specific consistent recommendations for drug therapy. Five published guidelines assist the clinician in therapeutic drug management of the acute exacerbation of COPD, and each differs in its recommendations for drug therapy prescription. The article includes synopses for drug therapy recommendations from the guidelines.
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Affiliation(s)
- Rebecca Haynes Hockman
- Medical Intensive Care Unit, Department of Pharmacy, University of Virginia Health Sciences Center, PO Box 800674, Charlottesville, VA 22908-0674, USA.
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Salpeter SR. Cardiovascular safety of beta(2)-adrenoceptor agonist use in patients with obstructive airway disease: a systematic review. Drugs Aging 2004; 21:405-14. [PMID: 15084142 DOI: 10.2165/00002512-200421060-00005] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND beta(2)-Adrenoceptor agonists have been used as bronchodilators in the management of asthma and chronic obstructive pulmonary disease (COPD); however, there is evidence suggesting that beta(2)-adrenoceptor agonist use may increase morbidity and mortality. METHODS A systematic review of case-control studies and randomised controlled trials was performed to evaluate the cardiovascular safety of beta(2)-adrenoceptor agonist use in patients with obstructive airway disease, defined as asthma or COPD. RESULTS Case-control studies have shown that beta(2)-adrenoceptor agonist use is associated with an increased risk of myocardial infarction, congestive heart failure, cardiac arrest and sudden cardiac death. The degree of risk appears to be dose-dependent, and may be highest for new users and those with concomitant cardiac conditions. Pooled data from randomised placebo-controlled trials indicate that beta(2)-adrenoceptor agonist use increases the risk of adverse cardiovascular events by more than 2-fold compared with placebo, thus providing evidence that the association seen in case-control studies is a causal one. Single doses of beta(2)-adrenoceptor agonists significantly increase heart rate and decrease potassium concentrations compared with placebo. CONCLUSIONS Initiation of beta(2)-adrenoceptor agonist treatment increases heart rate and decreases potassium concentrations, while continued use may increase the risk of adverse cardiovascular events. It could be through these effects of beta-adrenergic stimulation that beta(2)-adrenoceptor agonists may induce ischaemia, congestive heart failure, arrhythmias and sudden cardiac death. In addition to increasing adverse cardiovascular events, beta(2)-adrenoceptor agonist use may induce respiratory tolerance and increase the risk of asthma attacks. It is not clear whether beta(2)-adrenoceptor agonists should be used regularly in the treatment of obstructive airway disease, with or without concomitant cardiovascular disease.
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Abstract
The mammalian tachykinins are a family of peptides that, until recently, has included substance P (SP), neurokinin A and neurokinin B. Since, the discovery of a third preprotachykinin gene ( TAC4), the number of tachykinins has more than doubled to reveal several species-divergent peptides. This group includes hemokinin-1 (HK-1) in mouse and rat, endokinin-1 (EK-1) in rabbit, and EKA, EKB, human HK-1 (hHK-1) and hHK(4-11) in humans. Each exhibits a remarkable selectivity and potency for the tachykinin NK(1) receptor similar to SP. Their peripheral expression has led to the proposal that they are the endogenous peripheral SP-like endocrine/paracrine agonists where SP is not expressed. Moreover, their strong cross-reactivity with a specific SP antibody leads us to question many of the proposed locations and roles of SP in the periphery. Additionally, three orphan tachykinin gene-related peptides are identified on TAC4, in rabbit, EK-2 and in humans, EKC and EKD.
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Affiliation(s)
- N M Page
- School of Animal and Microbial Sciences, The University of Reading, RG6 6AJ Reading, United Kingdom.
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Krishna G, Sankaranarayanan V, Chitkara RK. New therapies for chronic obstructive pulmonary disease. Expert Opin Investig Drugs 2004; 13:255-67. [PMID: 15013944 DOI: 10.1517/13543784.13.3.255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is the most common lung disease, carrying a significant mortality and morbidity. None of the therapeutic interventions currently available alter the progression of the disease. As our understanding of the basic mechanisms of alveolar destruction and airflow limitation improves, new targets are identified that may eventually result in treatment options which will affect the progression of this disease. In this review, we discuss some of the novel therapeutic options recently developed that may have an impact on the management of COPD. Future directions in research and development of pharmacological agents based on improved understanding of COPD are also discussed.
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Affiliation(s)
- Ganesh Krishna
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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Suissa S, Assimes T, Brassard P, Ernst P. Inhaled corticosteroid use in asthma and the prevention of myocardial infarction. Am J Med 2003; 115:377-81. [PMID: 14553873 DOI: 10.1016/s0002-9343(03)00393-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asthma patients may be at increased risk of cardiovascular outcomes due to hypoxemia from asthma exacerbations and bronchodilator-induced tachycardia. We investigated whether inhaled corticosteroids, which are known to improve asthma control and reduce exacerbations, are associated with a lower rate of myocardial infarction. METHODS We used the Saskatchewan Health databases to form a population-based cohort of subjects aged 5 to 44 years who were using antiasthma drugs between 1975 and 1991. Subjects were followed until 1997, the age of 55 years, or death. A nested case-control approach was used where each subject with a first myocardial infarction was matched on calendar time, age, and sex with up to 10 controls randomly selected from the cohort. RESULTS The cohort consisted of 30,569 subjects, including 105 patients with myocardial infarction who were matched with 933 controls. The adjusted rate ratio of myocardial infarction for inhaled corticosteroid use during the year before the index date was 0.56 (95% confidence interval [CI]: 0.32 to 0.99) as compared with no use. Myocardial infarction decreased by 12% (95% CI: 0% to 23%) with each additional canister used during this 1-year period. The rate ratio of myocardial infarction for inhaled corticosteroid use was 0.78 (95% CI: 0.41 to 1.51) among patients with milder asthma and 0.19 (95% CI: 0.04 to 0.97) among those with more severe asthma. CONCLUSION Inhaled corticosteroid use may reduce the risk of myocardial infarction in asthma patients, particularly those with more severe disease.
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Affiliation(s)
- Samy Suissa
- Division of Clinical Epidemiology, Royal Victoria Hospital, and Epidemiology and Biostatistics and Medicine, McGill University, Montreal, Québec, Canada.
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Ziedalski TM, Sankaranarayanan V, Chitkara RK. Advances in the management of chronic obstructive pulmonary disease. Expert Opin Pharmacother 2003; 4:1063-82. [PMID: 12831334 DOI: 10.1517/14656566.4.7.1063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible airflow limitation with extreme economic and social burden. It is estimated that over the next two decades, it will become the 5(th) most prevalent disease and the 3(rd) most common cause of death in the world. A better understanding of the pathogenesis of airway inflammation and alveolar destruction allows for the development of new therapeutic targets. Tobacco smoking is the most important risk factor in the development of COPD, thus making smoking cessation of the outermost importance. This article provides a critical review of present therapy for COPD. In addition to conventional treatment (bronchodilators, corticosteroids and antibiotics) and smoking cessation therapies, novel approaches with potential benefit are discussed.
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Affiliation(s)
- Tomasz M Ziedalski
- Medical Service, Pulmonary Section, Veterans Affairs Palo Alto Healthcare System, USA.
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