Heartbeat: Heart failure and obstructive lung disease: are beta-blockers underused?

Current guidelines for management of heart failure (HF) recommend beta-blocker therapy even in patients with chronic obstructive pulmonary disease (COPD). However, many clinicians find it counterintuitive to treat COPD patients with beta-blockers either because of concerns that beta-blockers might negate the effects of inhaled beta-agonists or because beta-blockers might even provoke bronchoconstriction. Lipworth and colleagues ( see page 1909 ) studied the “real-life” use of beta-blocker therapy based on anonymous longitudinal electronic medical record data from over 2.4 million patients in the UK that included almost 90 thousand COPD and 24 thousand HF patients who were followed for more than one year. About 12% of the COPD patients also had HF; these 10 thousand COPD+HF patients (mean age 79 years, 60% male) were compared to a similar number of patients with HF alone. In patients treated with an angiotensin converting enzyme inhibitor (ACEI) or angiotensin-2 receptor blocker (ARB), only 22% of the COPD patients also were taking a beta-blocker, compared to 41% of the patients with HF but no COPD (adjusted OR 0.54, 95% CI 0.51 to 0.58, p<0.001) (figure 1). Similarly, beta blocker use was less common in COPD patients treated with inhaled medications. Figure 1 Prescription of β-blocker (BB) and ACEI (ACE inhibitor) or angiotensin-2 receptor blocker (ARB) for patients with heart failure (HF) alone versus patients with HF and chronic obstructive pulmonary disease (COPD)—showing data for all patients and split by New York Heart Association (NYHA) class. Data for adjusted ORs are shown with 95% CI. This article generated a great deal of social media interest, primarily among members of the general public, rather than researchers or clinicians. In a letter to the editor, Cunnington ( see page 1934 ) points out the importance of distinguishing patients with HF with preserved ejection fraction (HFpEF) from those with a …