Beta blockers underused in the elderly with lung disease

The underuse of beta blockers in elderly patients with lung disease was highlighted at the recent British Society for Heart Failure (BSH) 4th annual medical training meeting, held in London. Dr Suzanna Hardman (Consultant Cardiologist, The Whittington Hospital, London) told delegates that whilst 65% of patients admitted to hospital with heart failure are discharged on a beta blocker, less than 15% of elderly patients with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) take this evidence-based prognostic class of drugs.

There is incontrovertible, large-scale, randomised-controlled evidence for morbidity and mortality benefit of beta-blockers in heart failure (trials include MERIT-HF, COPERNICUS, CIBIS II),^1-3 she said, but the evidence for adverse effects in lung disease is based on animal studies, case reports and small scale human studies.⁴ Beta blockade in COPD, however, is fully endorsed by The European Society of Cardiology (ESC), National Institute for Clinical Excellence (NICE) and Cochrane reviews.^5-7

Dr Hardman’s presentation highlighted for trainees an important area where significant improvements can be achieved. Cardiac and respiratory function are closely interlinked, as demonstrated by worse prognoses in COPD exacerbations associated with elevations in brain natriuretic peptide (BNP) or troponin, while measures of lung function can improve by up to 30% with treatment of CHF.  Furthermore, COPD and CHF often co-exist and the presence of both is associated with excess mortality.  Although accurate diagnoses of CHF and COPD can be challenging, clinicians should make extended efforts to ensure optimal monitoring and treatment of both conditions.  Establishing an accurate diagnosis of obstructive airways disease requires spirometry assessment, peak-flow monitoring and support from respiratory physicians.

Beta blockade is advocated as safe in COPD and there is emerging evidence that it may also reduce exacerbations.  Institution of beta blockers in obstructive airways disease should be at low initial doses with gradual uptitration whilst monitoring lung function. Until long-term data are available, beta blockers should be used with caution and under close monitoring in asthma patients.

The training day included many other informative presentations from experts in the fields and opportunities for trainees to interact enabling them to gain a detailed understanding of difficult issues in the management of CHF.

References

1. MERIT-HF Study Group.  Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999;353:2001–7. http://dx.doi.org/10.1016/S0140-6736(99)04440-2
2. Packer M, Coats AJ, Fowler MB, et al. Effect of carvedilol on survival in severe chronic heart failure.  N Engl J Med 2001;344:1651–8. http://dx.doi.org/10.1056/NEJM200105313442201
3. CIBIS-II Investigators and Committees.  The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999;353:9–13. http://dx.doi.org/10.1016/S0140-6736(98)11181-9
4. van der Woude HJ, Zaagsma J, Postma DS, et al.  Detrimental effects of beta-blockers in COPD: a concern for non-selective beta-blocers.  Chest 2005;127:818–24. http://dx.doi.org/10.1378/chest.127.3.818
5. Dickstein K, Cohen-Solal A, Filippatos G, et al.  ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology.  Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).  Eur J Heart Fail 2008;10:933–89. http://dx.doi.org/10.1016/j.ejheart.2008.08.005
6. NICE (2010), Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care.  http://publications.nice.org.uk/chronic-heart-failure-cg108
7. Salpeter SR, Ormiston TM, Salpeter EE.  Cardioselective beta-blockers for chronic obstructive pulmonary disease.  Cochrane Database Syst Rev 2005;4: CD003566