Beta-Blockers for the Prevention of Acute Exacerbations of COPD

Chronic obstructive pulmonary disease (COPD) recently surpassed stroke as the 3rd leading cause of death in the United States and accounts for more than $40 billion annually in direct and indirect health care costs.(1, 2) COPD affects approximately 6% of civilians and at least 8% of the Veteran population though the prevalence is increasing in both groups and when Veterans with respiratory complaints are evaluated with spirometry and questionnaires rates of COPD may be as high as 43%.(3) Veterans with COPD also account for significantly higher all-cause and respiratory-related inpatient and outpatient health care utilization including number of physician encounters, emergency room visits, acute inpatient discharges, total bed days of care, pharmacy costs and total costs than those without COPD. Though existing pharmacotherapy can improve symptoms, quality of life and modestly reduce the risk of acute exacerbations, no treatments alter the natural history of the disease or improve mortality. COPD is also associated with an increased risk of a number of major comorbid illnesses, most importantly including cardiovascular disease which complicates diagnosis and management.(4) Despite clear evidence that beta-blockers markedly reduce cardiovascular risk in patients with and without COPD, concerns regarding their potential adverse respiratory effects have led to their dramatic underuse in COPD patients.(5, 6) This practice pattern persists despite recent observational data suggesting that beta-blockers may actually also improve respiratory outcomes in COPD patients.(7-10) These data require validation and thus the proposed clinical trial of beta-blockers to prevent exacerbations of COPD addresses the most important chronic lower respiratory tract illness in the United States, will test the efficacy of a novel approach to prevent its most morbid and costly consequences, and will provide critical information needed to shape guideline recommendations regarding the management of patients with co-morbid cardiovascular disease.