Bottom line: This study shows that the mist-inhaler formulation of tiotropium is associated with an increased risk of cardiovascular mortality.
Citation: Singh S, Loke YK, Enright PL, Furnberg CD. Mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis of randomised controlled trials. Br Med J. 2011;342: d3215.
B-Type Natriuretic Peptide (BNP) Is an Independent Predictor of Cardiovascular Events in Patients Undergoing Vascular Surgery
Clinical question: Can preoperative natriuretic peptide levels be used to independently predict perioperative cardiovascular events in patients undergoing vascular surgery?
Background: Currently we use the type of surgery, exercise tolerance, and clinical risk factors to predict perioperative cardiovascular risk. Clinical risk factors, based on the Revised Cardiac Risk Index, or RCRI, include history of ischemic heart disease, heart failure, cerebrovascular events, diabetes mellitus, and renal insufficiency. Recent studies have shown that the pre-operative natriuretic peptides can independently predict perioperative cardiovascular events.
Study design: Individual patient meta-analysis.
Setting: Data sets obtained from six multinational studies.
Synopsis: This meta-analysis included datasets from five studies that used BNP (632 patients) and one study that used NT-proBNP (218 patients) to assess the postoperative cardiovascular events in patients undergoing vascular surgery. Patients with elevated BNP level are at a higher risk of cardiac death (OR 4.3, 95% CI: 1.7-11.3) and all-cause mortality (OR 3.1, 95% CI: 1.4-6.7) within 30 days of vascular surgery. When the RCRI-based groups were reclassified using natriuretic peptide level, the improvement in discrimination was statistically significant. Limitations of this study include: 1) Individual patient data was not obtained for all studies that met the search criteria; and 2) Different types of BNP assays were used in different studies included.
Bottom line: Preoperative BNP level is an independent predictor of cardiovascular events at 30 days after vascular surgery. The addition of preoperative BNP level improves the predictive performance of the RCRI score.
Citation: Rodseth RN, Lurati Buse GA, Bolliger D, et al. The predictive ability of pre-operative B-type natriuretic peptide in vascular patients for major adverse cardiac events: an individual patient data meta-analysis. J Am Coll Cardiol. 2011;58:522-529.
Beta-Blockers May be Beneficial in Patients with Chronic Obstructive Pulmonary Disease
Clinical question: Is it beneficial to use beta-blockers in patients with chronic obstructive pulmonary disease (COPD) if there is an indication?
Background: Patients with COPD may have concomitant cardiovascular disease, which may warrant use of beta-blockers. Many physicians are concerned about using beta-blockers in COPD patients due to the risk of bronchospasm. Evidence suggests that cardio-selective beta-blockers do not cause deterioration of pulmonary status in COPD patients. There is also growing evidence that beta-blockers may be beneficial in patients with COPD.
Study design: Retrospective cohort study.
Setting: Data obtained from a disease-specific (COPD) database in Scotland.
Synopsis: This study included 5,977 patients who were older than 50 and excluded patients with history of malignancy. Beta-blockers were associated with a 22% reduction in all-cause mortality. There was no significant difference between cardio-selective and nonselective beta-blockers. The benefits of beta-blockers in COPD patients were independent of history of cardiovascular disease. There was no significant decline in pulmonary function (FEV1) over time. Beta-blocker usage also reduced the number of hospital admissions for COPD exacerbation. These benefits were shown in patients using different type of inhalers.
Bottom line: In patients older than 50, beta-blockers may not only reduce COPD exacerbations and hospital admissions, but also reduce all-cause mortality without adversely affecting pulmonary function.