Elsy Viviana Navas, MD Department of Cardiovascular Medicine, Cleveland Clinic
David O. Taylor, MD Department of Cardiovascular Medicine, Critical Care Center, and Transplantation Center, Cleveland Clinic
Address: David O. Taylor, MD, Department of Cardiovascular Medicine, J3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail taylord2@ccf.org
NONSELECTIVE BETA-BLOCKERS
Recent studies suggest that nonselective beta-blockers can affect respiratory function in patients with COPD, but they have failed to show any harm. For example, propranolol (Inderal) was shown to worsen pulmonary function and to decrease the sensitivity of the airway to the effects of long-acting beta-2-agonists, but the 15 patients included in this study had no increase in respiratory symptoms.8
It has also been suggested that combined nonselective beta- and alpha-receptor blockade—eg, with labetalol (Trandate) or carvedilol (Coreg)—might be better tolerated than nonselective beta-blockers in patients with COPD.9 However, from limited data, Kotlyar et al10 suggested that carvedilol may be less well tolerated in patients with asthma than with COPD. All current evidence on combined nonselective beta-and alpha-blockade is observational, and it is not yet clear whether this class of beta-blockers is better tolerated due to alpha-blockade or merely because nonselective beta-blockers themselves are well tolerated.
OUR RECOMMENDATIONS
Beta-blockers improve survival rates in patients with chronic systolic heart failure and after myocardial infarction, including in those patients with coexisting COPD and reactive airway disease. But not all beta-blockers are the same (Table 1). Cardioselective beta-blockers (ie, those that block predominantly beta-1 receptors) are our beta-blockers of choice based on stronger evidence from clinical studies. Nonselective agents that include alpha-adrenergic blockade can be considered, although less is known about their effect on respiratory function. However, the use of even beta-1-selective drugs merits caution and close follow-up in patients with severe asthma (for which clinical study data are limited).
