@ERSpublications Treatment with bronchodilators in COPD patients should take into account cardiovascular comorbidities http://ow.ly/gMIG30aAwTKCite this article as: Agabiti N, Corbo GM. COPD and bronchodilators: should the heart pay the bill for the lung? Eur Respir J 2017; 49: 1700370 [https://doi.org/10.1183/13993003.00370-2017.
The questionThe pharmacological treatment of patients with coexisting cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD) is challenging, because some drugs for COPD patients should be used with caution in patients with CVD, and vice versa. The crucial question on cardiovascular safety of long-acting bronchodilators, i.e. long-acting β 2 -agonists (LABAs) and long-acting anti-muscarinic agents (LAMAs, principally tiotropium), has no definitive answer. Because of different mechanisms of action, the combination of these drugs is expected to be more effective than the individual components in the maintenance treatment of COPD [1]. Evidence available from randomised controlled trails and observational studies on increased risk of cardiovascular adverse events is large but difficult to summarise because of complex methodology, different comparison groups and potential bias in each study [2][3][4][5]. Results are controversial and inconclusive. The risks of combining LABAs and tiotropium for the treatment of COPD are still unclear. Whether COPD patients treated with long-acting bronchodilators have increased risk of heart failure, or patients with both COPD and heart failure have higher risk of adverse events, remain open questions.
What the study addsIn this issue of the European Respiratory Journal, the study presented by SUISSA et al.[6] interestingly contributes to the ongoing debate. The focus is on the concurrent use of long-acting bronchodilators. A large COPD patient cohort was selected from the UK Clinical Practice Research Datalink for 2002-2012 and followed up over 1 year. Compared with monotherapy, adding a second long-acting bronchodilator (either a LABA or tiotropium) did not increase the risk of myocardial infarction, stroke or arrhythmia. However, a statistically significant 16% increase in the risk of heart failure was found with the addition of a second long-acting bronchodilator rather than monotherapy; the increase was higher (23%) when patients with previous diagnosis of heart failure (about 3% of the whole study population) were excluded. Large numbers from real-world settings, sophisticated analytical approaches and sensitivity analyses led to robust results, considering the known limits of observational studies on the comparative effectiveness and safety of drugs. The fact that the use of two long-acting bronchodilators was found to be safe, in terms of major cardiovascular events, is reassuring and supports the guidelines/recommendations regarding the use of fixed-dose combination bronchodilators. However, the effect on heart failure is relevant and deserves some additional consideration.