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

Assessment of the right ventricular strain, left ventricular strain and left atrial strain using speckle tracking echocardiography in patients with chronic obstructive pulmonary disease

OBJECTIVES

Cardiovascular disease is a prevalent comorbidity and leading cause of mortality in chronic obstructive pulmonary disease (COPD) patients. Early identification of cardiac abnormalities in COPD patients is crucial. Speckle tracking echocardiography (STE) is practical for assessing ventricular and atrial function, but its role in COPD patients is under-researched. This study aimed to examine right ventricular (RV), left ventricular (LV) and left atrial (LA) strain in COPD patients via STE.

METHODS

A cross-sectional study was conducted with two groups: COPD patients diagnosed per the 2017 Global Initiative for Chronic Obstructive Lung Disease criteria and healthy controls. All the participants underwent STE to evaluate the RV, LV, and LA strains.

RESULTS

RV strain indices (RV free wall longitudinal strain (RVFWSL) and RV 4-chamber longitudinal strain (RV4CSL)) were significantly lower in the COPD group (16.53±5.89% and 14.65±4.53%, respectively) than in the control group (21.39±7.78% and 18.34±6.38%, respectively) (p<0.001). LV global longitudinal strain was also lower in the COPD group (18.45% (17.16-19.51)) than in the control group (19.50% (18.63-21.46), p=0.018). No significant differences were found in LA strain indices (LA reservoir strain, LA conduit strain or LA contractile strain) between the two groups. Furthermore, RVFWSL and RV4CSL were significantly greater in the group with a modified Medical Research Council score <2 (p<0.05).

CONCLUSION

Compared with healthy controls, COPD patients presented reduced RV and LV strain, with no significant differences in LA strain indices.

Prognostic impact of chronic obstructive pulmonary disease in patients with heart failure with mildly reduced ejection fraction

BACKGROUND

The aging population has led to a significant increase in heart failure (HF) patients. Related to demographic changes, the burden with comorbidities was shown to increase in patients with HF. Whereas chronic obstructive pulmonary disease (COPD) was yet demonstrated to be associated with adverse outcomes in patients with HF, the prognostic impact of COPD in HF with mildly reduced ejection fraction (HFmrEF) has not yet been clarified.

OBJECTIVE

The study investigates the prognostic impact of COPD in patients hospitalized with HFmrEF.

METHODS

Consecutive patients with HFmrEF were retrospectively included at one institution from 2016 to 2022. Patients with COPD were compared to patients without with regard to the primary endpoint all-cause mortality at 30 months (median follow-up). Secondary endpoints comprised in-hospital mortality, HF-related re-hospitalization, cardiac re-hospitalization and major adverse cardiac and cerebrovascular events (MACCE) at 30 months.

RESULTS

A total of 2184 patients with HFmrEF were included with a prevalence of COPD of 12.0 %. Patients with COPD were older (median 77 vs. 75 years; p = 0.025), had increased burden of cardiovascular comorbidities and more advanced HF symptoms. At 30 months, patients with COPD had an increased risk of all-cause mortality compared to patients without (45 % vs. 30 %; HR = 1.667; 95 % CI 1.366-2.034; p = 0.001), alongside with a higher risk of re-hospitalization for worsening HF (20 % vs. 12 %; HR = 1.658; 95 % CI 1.218-2.257; p = 0.001).

CONCLUSION

COPD is independently associated with adverse outcomes in patients hospitalized with HFmrEF.

A Literature Review on the Coexisting Chronic Obstructive Pulmonary Disease and Heart Failure

The convergence of chronic obstructive pulmonary disease (COPD) and heart failure (HF) is a prevalent yet often overlooked medical scenario. This coexistence poses diagnostic challenges due to symptom similarities. This comprehensive review extensively examines the impact of COPD and HF on pharmacological management. Furthermore, the concurrent presence of these conditions amplifies both mortality rates and societal financial strain. Addressing these intertwined ailments necessitates a multidisciplinary approach. Within this review, we delve into the foundational mechanisms, diagnostic intricacies, and available management choices for these closely related conditions.

Beta-blocker use in patients with chronic obstructive pulmonary disease: A systematic review: A systematic review of βB in COPD

Beta-blockers (βB) are a frequently used class of medications. Although βB have many indications, those related to cardiovascular disease are among the most common and important. However, in patients with chronic obstructive pulmonary disease (COPD), βB are used less often due to concerns about an unfavorable impact on respiratory morbidity and mortality. We performed a systematic review to assess the safety of βB in patients with COPD. We included a total of 2 randomized controlled trials and 28 observational studies. The majority found statistically significant reductions in mortality. The two higher quality observational studies reported increased mortality with βB. The risk of COPD exacerbations was reduced in about half of the studies. Nonetheless, there were significant biases that confounded the results. The highest quality RCT found a significant increase in severe and very severe COPD exacerbations with βB use. In conclusion, data on the safety of βB in patients with COPD are conflicting. However, given higher quality evidence showed harm with their use, βB should be prescribed with caution in patients with COPD, including patients with cardiac indication for βB.

MIR-548ar-3p increases cigarette smoke extractinduced chronic obstructive pulmonary disease (COPD) injury through solute carrier family 17 member 9 (SLC17A9)

This study investigated the effect of microRNA mir-548ar-3p on cigarette smoke extract (CSE)-induced chronic obstructive pulmonary disease (COPD). High-throughput sequencing was performed on peripheral blood from smoking COPD patients and non-smoking individuals with normal pulmonary function, and mir-548ar-3p RNA, possessing large differential expression was selected. Experimental groups were divided into control, experimental model (EM), EM+mimic miRNA, negative control (NC) and EM+miR-548ar-3p groups; an empty vector or miR-548ar-3p mimic was transfected into human bronchial epithelial (HBE) cells. A COPD model was established by treating HBE cells with CSE. Cell viability, apoptosis and solute carrier family 17 member 9 (SLC17A9) protein expression were examined by cell counting kit-8, flow cytometry and Western blotting, respectively. Cell viability in the EM+miR-548ar-3p group decreased significantly, and the apoptosis rate and SLC17A9 protein expression increased significantly compared with the control (P<0.05, all groups). In smoking COPD patients, interferon (IFN)-? and interleukin (IL)-17? expression detected by ELISA was significantly higher than in normal individuals. miR-548ar-3p expression was significantly lower (P<0.05, all groups). These findings suggest that miR-548ar-3p was expressed at a lower level in COPD patients. miR-548ar-3p may increase the extent of CSE-induced COPD injury through SLC17A9.

The Coexistence of Chronic Obstructive Pulmonary Disease and Heart Failure

Chronic obstructive pulmonary disease (COPD) is a chronic illness that is widely prevalent within the United States and has been frequently associated with heart failure (HF). COPD is associated with progressive damage and inflammation of the airways leading to airflow obstruction and inadequate gas exchange. HF represents a decline in the normal functioning of the heart resulting in insufficient pumping of blood through the circulatory system. COPD and HF present with similar signs and symptoms with some variation.

There are many specific diagnostic tests and treatment modalities which we use to diagnose COPD and HF, but it becomes an issue when you come across a patient who has both conditions simultaneously. For example, attempting to use an X-ray to diagnose HF in a COPD patient is next to impossible because the results are manipulated by the COPD disease process. This is the case with many other diagnostic tests such as an electrocardiogram (ECG), chest radiography (X-ray), B-type natriuretic peptide (BNP), echocardiogram, cardiac magnetic resonance imaging (CMR), pulmonary function test (PFT), arterial blood gas (ABG), and exercise stress testing.

When a patient has both COPD and HF, it becomes more difficult to treat. Many treatments for HF have negative impacts on COPD patients and vice-versa, whereas some have also shown positive clinical outcomes in both diseases. It is agreeable that treatment has to be patient-centered and it can vary from case to case depending on the severity of the disease. Ultimately, in this review, we discuss COPD and HF and how they interplay in their diagnostic and treatment modalities to gain a better understanding of how to effectively manage patients who have been diagnosed with both conditions.

Beta-blocker therapy in patients with COPD: a systematic literature review and meta-analysis with multiple treatment comparison

BACKGROUND

Beta-blockers are associated with reduced mortality in patients with cardiovascular disease but are often under prescribed in those with concomitant COPD, due to concerns regarding respiratory side-effects. We investigated the effects of beta-blockers on outcomes in patients with COPD and explored within-class differences between different agents.

METHODS

We searched the Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline for observational studies and randomized controlled trials (RCTs) investigating the effects of beta-blocker exposure versus no exposure or placebo, in patients with COPD, with and without cardiovascular indications. A meta-analysis was performed to assess the association of beta-blocker therapy with acute exacerbations of COPD (AECOPD), and a network meta-analysis was conducted to investigate the effects of individual beta-blockers on FEV1. Mortality, all-cause hospitalization, and quality of life outcomes were narratively synthesized.

RESULTS

We included 23 observational studies and 14 RCTs. In pooled observational data, beta-blocker therapy was associated with an overall reduced risk of AECOPD versus no therapy (HR 0.77, 95%CI 0.70 to 0.85). Among individual beta-blockers, only propranolol was associated with a relative reduction in FEV1 versus placebo, among 199 patients evaluated in RCTs. Narrative syntheses on mortality, all-cause hospitalization and quality of life outcomes indicated a high degree of heterogeneity in study design and patient characteristics but suggested no detrimental effects of beta-blocker therapy on these outcomes.

CONCLUSION

The class effect of beta-blockers remains generally positive in patients with COPD. Reduced rates of AECOPD, mortality, and improved quality of life were identified in observational studies, while propranolol was the only agent associated with a deterioration of lung function in RCTs.

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

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

Beta-blockers in COPD: A systematic review based on recent research

Chronic obstructive pulmonary disease (COPD) with cardiovascular complications is very common. Due to fear of exacerbating airway spasm, β-blockers are rarely used in such patients. Many observational studies suggest that β-blockers can reduce the disease progression and the risk of mortality in patients with COPD, but lack of confirmation from randomized controlled trials. This article reviews the application of β-blockers in patients with COPD based on the results of the latest published randomized controlled trials.

Beta-blocker Use in Moderate and Severe Chronic Obstructive Pulmonary Disease

Introduction:

The most appropriate choice of pharmacological treatment of heart rhythm disorders occurring in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular comorbidity is often a topic of debate between pulmonologists and cardiologists in clinical practice, although numerous studies and clinical trials have demonstrated evidence to support the use of selective beta-blockers (BBs) in these patients.

Aim:

To examine the difference in the number of exacerbations in patients treated with a combination of verapamil and digoxin or BB alone in patients with different COPD stages.

Patients and methods:

The study included 68 patients (n = 68) diagnosed with COPD who were followed-up during a 12-month period, and the number of exacerbations were analyzed. The patients were divided into two groups according to the stage of COPD: GOLD II (moderate), and GOLD III (severe), and in each group a subdivision was established in relation to the use of either a combination of verapamil and digoxin or the use of BBs alone in pharmacological treatment. The inclusion criteria for patients were defined as following: a) established diagnosis of COPD according to present or deteriorated relevant clinical symptoms and signs, b) the ejection fraction (EF) of a left ventricle (LV) >35%, and c) spirometric cut-points classified as GOLD II (FEV1 / FVC <0.7, FEV1 predicted 50-80%), or GOLD III (FEV1/FVC <0.7, FEV1 predicted 30-50%) stage of the COPD. The exclusion criteria were EF of LV <35% and a lethal outcome during a follow-up period (2 patients were encountered). Exacerbation was defined as functional deterioration of the COPD symptoms verified by spirometric functional testing, frequency of hospitalizations according to GOLD stage assignment or verified clinical symptoms deterioration.

Results:

Regardless the pharmacological treatment, there is a statistically significant increase in the number of COPD exacerbations, in a 12-month period follow-up, in the GOLD III group (severe) compared to the GOLD II group (moderate). In the group of patients taking verapamil and digoxin, a two-tailed t-test was used to analyze the results between the GOLD II and GOLD III stage groups, p = 0.01, and 2. In the group of patients taking BBs, a two-tailed t-test was also used to analyze the results between the GOLD II and GOLD III stage groups, p = 0.003). Within the COPD GOLD II stage group, there appears to be no statistically significant difference in the number of exacerbations between the patients taking verapamil and digoxin (n = 24) and the patients taking BBs alone (n = 15), although, in patients taking BBs alone, there appears to be a trend towards a decrease in the exacerbations compared to the number of exacerbations in patients taking verapamil and digoxin (p = 0.007). Within the COPD GOLD III stage group, there is no difference in the number of exacerbations between the patients taking verapamil and digoxin (n = 20), and the patients taking BBs alone (n = 9), as analyzed by a two-tailed t-test, p = 0.577.

Conclusion:

Use of selective BBs in the treatment of cardiovascular comorbidity in patients with COPD represents a far better choice of pharmacological approach in the treatment of patients diagnosed with COPD GOLD II (moderate) stage.

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

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

COPD and Cardiovascular Disease

COPD is one of the major public health problems in people aged 40 years or above. It is currently the 4th leading cause of death in the world and projected to be the 3rd leading cause of death by 2020. COPD and cardiac comorbidities are frequently associated. They share common risk factors, pathophysiological processes, signs and symptoms, and act synergistically as negative prognostic factors. Cardiac disease includes a broad spectrum of entities with distinct pathophysiology, treatment and prognosis. From an epidemiological point of view, patients with COPD are particularly vulnerable to cardiac disease. Indeed, mortality due to cardiac disease in patients with moderate COPD is higher than mortality related to respiratory failure. Guidelines reinforce that the control of comorbidities in COPD has a clear benefit over the potential risk associated with the majority of the drugs utilized. On the other hand, the true survival benefits of aggressive treatment of cardiac disease and COPD in patients with both conditions have still not been clarified. Given their relevance in terms of prevalence and prognosis, we will focus in this paper on the management of COPD patients with ischemic coronary disease, heart failure and dysrhythmia.

Multidimensional approach for the proper management of a complex chronic patient with chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is frequently associated with comorbidities occurring either independently or as consequences of COPD. Areas covered: This review examines the interactions between the pathophysiology of COPD and the most frequent comorbidities, and highlights the need for multidimensional clinical strategies to manage COPD patients with comorbidities. Expert commentary: Most COPD patients need to be approached in a complex and multifactorial scenario. The diagnosis of COPD is necessarily based on the presence of chronic respiratory symptoms and poorly reversible airflow obstruction, but exacerbations and comorbidities need to be considered in the evaluation of disease severity and prognosis in individual patients. More importantly, defining the precise relationship between COPD and comorbidities for each patient is the basis for a correct therapeutic approach.

Beta-blockers are under-prescribed in patients with chronic obstructive pulmonary disease and co-morbid cardiac disease

The use of beta-blockers in patients with chronic obstructive pulmonary disease and co-morbid cardiovascular disease is controversial, despite increasing evidence to support their use as safe and efficacious. This study retrospectively assessed the rates of beta-blocker prescription in patients admitted to two Australian tertiary hospitals for acute exacerbation of chronic obstructive pulmonary disease. This revealed that less than half of patients (45%) with known cardiac indications were receiving beta-blocker therapy, evident across all degrees of airways disease severity. Further work is needed to ensure that medical management of this patient group is optimised.

Effect of β-blockade on lung function, exercise performance and dynamic hyperinflation in people with arterial vascular disease with and without COPD

Introduction

β Blockers are important treatment for ischaemic heart disease and heart failure; however, there has long been concern about their use in people with chronic obstructive pulmonary disease (COPD) due to fear of symptomatic worsening of breathlessness. Despite growing evidence of safety and efficacy, they remain underused. We examined the effect of β-blockade on lung function, exercise performance and dynamic hyperinflation in a group of vascular surgical patients, a high proportion of who were expected to have COPD.

Methods

People undergoing routine abdominal aortic aneurysm (AAA) surveillance were sequentially recruited from vascular surgery clinic. They completed plethysmographically measured lung function and incremental cardiopulmonary exercise testing with dynamic measurement of inspiratory capacity while taking and not taking β blocker.

Results

48 participants completed tests while taking and not taking β blockers with 38 completing all assessments successfully. 15 participants (39%) were found to have, predominantly mild and undiagnosed, COPD. People with COPD had airflow obstruction, increased airway resistance (Raw) and specific conductance (sGaw), static hyperinflation and dynamically hyperinflated during exercise. In the whole group, β-blockade led to a small fall in FEV1 (0.1 L/2.8% predicted) but did not affect Raw, sGaw, static or dynamic hyperinflation. No difference in response to β-blockade was seen in those with and without COPD.

Conclusions

In people with AAA, β-blockade has little effect on lung function and dynamic hyperinflation in those with and without COPD. In this population, the prevalence of COPD is high and consideration should be given to case finding with spirometry.

Trial registration number

NCT02106286.

Challenges of Treating Acute Heart Failure in Patients with Chronic Obstructive Pulmonary Disease

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) comorbidity poses substantial diagnostic and therapeutic challenges in acute care settings. The specific role of pulmonary comorbidity in the treatment and outcomes of cardiovascular disease patients was not addressed in any short- or long-term prospective study. Both HF and COPD can be interpreted as systemic disorders associated with low-grade inflammation, endothelial dysfunction, vascular remodelling and skeletal muscle atrophy. HF is regularly treated as a broader cardiopulmonary syndrome utilising acute respiratory therapy. Based on observational data and clinical expertise, a management strategy of concurrent HF and COPD in acute settings is suggested. Concomitant use of beta2-agonists and beta-blockers in a comorbid cardiopulmonary condition seems to be safe and effective.

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

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

Cardiac Arrhythmias in Patients with Exacerbation of COPD

Supraventricular and ventricular arrhythmias are common among patients with chronic obstructive pulmonary disease (COPD). Multiple factors can contribute to the development of arrhythmias in patients with exacerbation of the disease, including: respiratory or heart failure, hypertension, coronary disease and also medications. In the present study we seek to determine the prevalence of cardiac arrhythmias and risk factors among patients with exacerbation of COPD. The study was a retrospective evaluation of 2753 24-h Holter recordings of patients hospitalized in 2004-2016. Exacerbation of COPD was diagnosed in 152 patients and the prevalence of arrhythmias in this group of patients was 97%. The commonest arrhythmia was ventricular premature beats (VPB) - 88.8%, followed by supraventricular premature beats (SPB) - 56.5%. Permanent atrial fibrillation accounted for 30.3% and paroxysmal atrial fibrillation (PAF) for 12.5%. Supraventricular tachycardia (SVT) was noted in 34.2% patients and ventricular tachycardia in 25.6%. Respiratory failure increased the risk of SPB, while heart failure increased the risk of VPB. Treatment with theophylline was associated with a higher proportion of PAF and SVT. In conclusion, COPD exacerbation is associated with a high prevalence of cardiac arrhythmias. COPD treatment and comorbidities increase the risk of arrhythmias.

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

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

Characteristics of Beta-blocker Treatment in Cardiac Patients with Concomitant Chronic Obstructive Pulmonary Disease

Background: Recent scientific data demonstrated a potential beneficial effect of beta-blocker (BB) therapy in cardiac patients with chronic obstructive pulmonary disease (COPD). Our aim was to characterize the use of beta-blockers in these patients, in “real-life” conditions.

Material and methods: We collected retrospectively the data of 60 consecutive cardiac patients (51 men, 9 women, mean age 67 years) with the concomitant diagnosis of COPD: main cardiac conditions, presence and reason of BB therapy, type of drug and dosage, main ECG and echocardiographic parameters, medication and data regarding COPD. Besides descriptive statistics, we compared the data of patients with and without BB therapy (chi-square test, level of significance alpha <0.05) in order to identify factors associated with BB usage.

Results: In our study population, 41.6% of the patients had received BB treatment, the most frequently used drug being bisoprolol 2.5 mg and 5 mg q.d. (28%-28%), followed by carvedilol (32%). The prevalence of BB therapy was 51.2% in heart failure patients (48% in NYHA class III and IV, and 66.6% in dilated cardiomyopathy), 38.4% in hypertension, 81.8% in ischemic artery disease, and 64.7% in subjects with atrial fibrillation. The usage of BB therapy was significantly associated with the presence of heart failure (p = 0.047), dilated cardiomyopathy (p = 0.034), ischemic heart disease (p = 0.005), previous myocardial infarction (p = 0.003) and, inversely, with the acute exacerbation of COPD (p = 0.006).

Conclusions: Despite the fact that every cardiac patient with COPD had a potential indication for BB treatment, this was used insufficiently, especially in case of heart failure patients. In daily practice, there is a need for continuous review and improvement of BB usage in these patients.

Prevalence and burden of comorbidities in Chronic Obstructive Pulmonary Disease

The classical definition of Chronic Obstructive Pulmonary Disease (COPD) as a lung condition characterized by irreversible airway obstruction is outdated. The systemic involvement in patients with COPD, as well as the interactions between COPD and its comorbidities, justify the description of chronic systemic inflammatory syndrome. The pathogenesis of COPD is closely linked with aging, as well as with cardiovascular, endocrine, musculoskeletal, renal, and gastrointestinal pathologies, decreasing the quality of life of patients with COPD and, furthermore, complicating the management of the disease. The most frequently described comorbidities include skeletal muscle wasting, cachexia (loss of fat-free mass), lung cancer (small cell or non-small cell), pulmonary hypertension, ischemic heart disease, hyperlipidemia, congestive heart failure, normocytic anemia, diabetes, metabolic syndrome, osteoporosis, obstructive sleep apnea, depression, and arthritis. These complex interactions are based on chronic low-grade systemic inflammation, chronic hypoxia, and multiple common predisposing factors, and are currently under intense research. This review article is an overview of the comorbidities of COPD, as well as their interaction and influence on mutual disease progression, prognosis, and quality of life.

β-Blockers for the prevention of acute exacerbations of chronic obstructive pulmonary disease (βLOCK COPD): a randomised controlled study protocol

INTRODUCTION

A substantial majority of chronic obstructive pulmonary disease (COPD)-related morbidity, mortality and healthcare costs are due to acute exacerbations, but existing medications have only a modest effect on reducing their frequency, even when used in combination. Observational studies suggest β-blockers may reduce the risk of COPD exacerbations; thus, we will conduct a randomised, placebo-controlled trial to definitively assess the impact of metoprolol succinate on the rate of COPD exacerbations.

METHODS AND ANALYSES

This is a multicentre, placebo-controlled, double-blind, prospective randomised trial that will enrol 1028 patients with at least moderately severe COPD over a 3-year period. Participants with at least moderate COPD will be randomised in a 1:1 fashion to receive metoprolol or placebo; the cohort will be enriched for patients at high risk for exacerbations. Patients will be screened and then randomised over a 2-week period and will then undergo a dose titration period for the following 6 weeks. Thereafter, patients will be followed for 42 additional weeks on their target dose of metoprolol or placebo followed by a 4-week washout period. The primary end point is time to first occurrence of an acute exacerbation during the treatment period. Secondary end points include rates and severity of COPD exacerbations; rate of major cardiovascular events; all-cause mortality; lung function (forced expiratory volume in 1 s (FEV1)); dyspnoea; quality of life; exercise capacity; markers of cardiac stretch (pro-NT brain natriuretic peptide) and systemic inflammation (high-sensitivity C reactive protein and fibrinogen). Analyses will be performed on an intent-to-treat basis.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Department of Defense Human Protection Research Office and will be approved by the institutional review board of all participating centres. Study findings will be disseminated through presentations at national and international conferences and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02587351; Pre-results.

Treatment options for moderate-to-very severe chronic obstructive pulmonary disease

INTRODUCTION

The appropriate drug management of COPD is still based on the use of bronchodilators, possibly associated with an anti-inflammatory agent. However, there are still fundamental questions that require clarification to optimise their use and major unmet clinical needs that must be addressed.

AREAS COVERED

The advances obtained with the pharmacological options currently consolidated and the different approaches that are often used in an attempt to respond to unmet therapeutic needs are reviewed Expert opinion: In view of the unsatisfactory status of current treatments for COPD, there is an urgent need for alternative and more effective therapeutic approaches that will help to relieve patient symptoms and affect the natural course of COPD, inhibiting chronic inflammation and reversing the disease process or preventing its progression. However, new pharmacologic options have proved difficult to develop. Therefore, it is mandatory to optimize the use of the treatment options at our disposal. However, there are still fundamental questions regarding their use, including the step-up and step-down pharmacological approach, that require clarification to optimise the use of these drugs. It is likely that phenotyping COPD patients would help in identifying the right treatment for each COPD patient and improve the effectiveness of therapies.

β-Blockers are associated with a reduction in COPD exacerbations

BACKGROUND

While some retrospective studies have suggested that β-blocker use in patients with COPD is associated with a reduction in the frequency of acute exacerbations and lower mortality, there is concern that their use in patients with severe COPD on home oxygen may be harmful.

METHODS

Subjects with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2-4 COPD participating in a prospective follow-up of the COPDGene cohort, a multicentre observational cohort of current and former smokers were recruited. Total and severe exacerbation rates were compared between groups categorised by β-blocker use on longitudinal follow-up using negative binomial regression analyses, after adjustment for demographics, airflow obstruction, %emphysema on CT, respiratory medications, presence of coronary artery disease, congestive heart failure and coronary artery calcification, and after adjustment for propensity to prescribe β-blockers.

RESULTS

3464 subjects were included. During a median of 2.1 years of follow-up, β-blocker use was associated with a significantly lower rate of total (incidence risk ratio (IRR) 0.73, 95% CI 0.60 to 0.90; p=0.003) and severe exacerbations (IRR 0.67, 95% CI 0.48 to 0.93; p=0.016). In those with GOLD stage 3 and 4 and on home oxygen, use of β-blockers was again associated with a reduction in the rate of total (IRR 0.33, 95% CI 0.19 to 0.58; p<0.001) and severe exacerbations (IRR 0.35, 95% CI 0.16 to 0.76; p=0.008). Exacerbation reduction was greatest in GOLD stage B. There was no difference in all-cause mortality with β-blocker use.

CONCLUSIONS

β-Blockers are associated with a significant reduction in COPD exacerbations regardless of severity of airflow obstruction. The findings of this study should be tested in a randomised, placebo-controlled trial.

TRIAL REGISTRATION NUMBER

(ClinicalTrials.gov NCT00608764).

Impact of β-blocker selectivity on long-term outcomes in congestive heart failure patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is present in approximately one-third of all congestive heart failure (CHF) patients, and is a key cause of underprescription and underdosing of β-blockers, largely owing to concerns about precipitating respiratory deterioration. For these reasons, the aim of this study was to evaluate the impact of β-blockers on the long-term outcomes in CHF patients with COPD. In addition, we compared the effects of two different β-blockers, carvedilol and bisoprolol.

METHODS

The study was a retrospective, non-randomized, single center trial. Acute decompensated HF patients with COPD were classified according to the oral drug used at discharge into β-blocker (n=86; carvedilol [n=52] or bisoprolol [n=34]) and non-β-blocker groups (n=46). The primary endpoint was all-cause mortality between the β-blocker and non-β-blocker groups during a mean clinical follow-up of 33.9 months. The secondary endpoints were the differences in all-cause mortality and the hospitalization rates for CHF and/or COPD exacerbation between patients receiving carvedilol and bisoprolol.

RESULTS

The mortality rate was higher in patients without β-blockers compared with those taking β-blockers (log-rank P=0.039), and univariate analyses revealed that the use of β-blockers was the only factor significantly correlated with the mortality rate (hazard ratio: 0.41; 95% confidence interval: 0.17-0.99; P=0.047). Moreover, the rate of CHF and/or COPD exacerbation was higher in patients treated with carvedilol compared with bisoprolol (log-rank P=0.033). In the multivariate analysis, only a past history of COPD exacerbation significantly increased the risk of re-hospitalization due to CHF and/or COPD exacerbation (adjusted hazard ratio: 3.11; 95% confidence interval: 1.47-6.61; P=0.003).

CONCLUSION

These findings support the recommendations to use β-blockers in HF patients with COPD. Importantly, bisoprolol reduced the incidence of CHF and/or COPD exacerbation compared with carvedilol.

The Saudi Guidelines for the Diagnosis and Management of COPD

The Saudi Thoracic Society (STS) launched the Saudi Initiative for Chronic Airway Diseases (SICAD) to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease (COPD). This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test (CAT) and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation (<2 in the past year) can be classified as either Class I when they have less symptoms (CAT < 10) or Class II when they have more symptoms (CAT ≥ 10). High-risk COPD patients, as manifested with ≥2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score ≥10. The article also discusses the diagnosis and management of acute exacerbations in COPD.

β-Blockers and chronic obstructive pulmonary disease: inappropriate avoidance?

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States and is often accompanied by one or more comorbid conditions. While there are established morbidity and mortality benefits of β-blocker (BB) use for certain cardiovascular conditions, data suggest that clinicians are often reluctant to prescribe them in the presence of COPD because of concerns for bronchoconstriction, despite evidence that they are typically well-tolerated among these patients. Treatment guidelines for COPD are consistent with those for cardiovascular disease management and support the role of BBs in management of particular cardiovascular conditions, even in the presence of severe COPD. Adherence to these guidelines could result in significant decreases in morbidity and mortality among patients with COPD. Additionally, current treatments for COPD are often linked to increased cardiovascular disease events. Further study is needed to clarify and guide therapeutic management in patients with COPD.