Should Patients with COPD Exacerbations Receive Beta Blockers?
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: The findings of this retrospective study of 825 patients hospitalized with COPD exacerbations indicate that the use of beta blockers in such patients is not harmful and may actually be associated with reduced mortality.
Source: Dransfield MT, et al. Thorax. 2008 ;63(4):301-305.
This study from the University of Alabama Hospital in Birmingham reviewed administrative data from all patients admitted with the primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease (COPD), or because of acute respiratory failure with a secondary diagnosis of COPD exacerbation. The investigators excluded patients with asthma, and examined demographic data, co-morbidities, and medication use during hospitalization. Patients who received beta blockers were compared with those who did not, and multivariate analysis was performed to determine predictors of in-hospital mortality after controlling for known covariates and the propensity to receive beta blockers.
During the 7-year study period, 825 patients met inclusion criteria, 142 of whom received beta blockers. Patients who received beta blockers were older and more of them had concomitant cardiovascular disease. Overall, 5.2% of all patients died. By multivariate analysis, adjusting for potential confounders including the propensity score, mortality was less among patients who received beta blockers (odds ratio, 0.39, 95% CI 0.14-0.99). Mortality was also associated with older age, longer hospital stays, number of previous exacerbations, the presence of acute respiratory failure, congestive heart failure, and the presence of cardiovascular or liver disease (all, p < 0.05). The authors conclude that administration of beta blockers to patients hospitalized with COPD exacerbations is well tolerated and may be associated with reduced mortality.
Commentary
One of the most firmly entrenched "things everybody knows" in managing patients with obstructive lung disease is that beta-blocking agents cause bronchospasm and should not be used in such patients. While few would argue with this admonition in managing patients with severe asthma, it basically turns out not to be true for patients with COPD—especially for the cardioselective beta blockers now widely used in managing cardiovascular disease. A recent Cochrane review1 evaluated 20 randomized trials of cardioselective beta blockers in patients with COPD and found no significant effect on airway function (as assessed by forced expiratory volume in the first second, or the response to inhaled bronchodilator), either after single doses or with as much as 12 weeks of administration. In fact, there is an increasing body of evidence that beta blockers may improve outcomes in patients with COPD, whether or not they have overt cardiovascular disease.2
Because of their common link to cigarette smoking, as well as other potential factors, COPD and cardiovascular disease tend to occur in the same patients. There is compelling evidence that beta blockers improve outcomes in cardiovascular disease—not only in acute myocardial infarction, cardiac ischemia, and left ventricular systolic dysfunction, but also in hypertension and other settings.2 However, because of fear of precipitating acute bronchospasm, and widespread acceptance of the idea that beta blockers are contraindicated in obstructive lung disease, these agents are used less often in patients with COPD when the established indications are present. In the current study, of the 306 patients in the cohort who were considered to have a clear indication for beta blocker administration, only 28% received this therapy.
Beta blockers are not contraindicated in COPD, either in the long-term management of stable patients or during hospitalization for an exacerbation. There is even the suggestion that beta blockers may be indicated for patients with COPD, although this hypothesis needs to be tested in randomized clinical trials.
References
- Salpeter S, et al. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(4):CD003566.
- Au DH. Thorax. 2008;63:296-298.
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