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STATE OF THE ART

Therapeutic update: Non-selective beta- and alpha-adrenergic blockade in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure

Tseday E. Sirak, MD^*, Sanja Jelic, MD and Thierry H. Le Jemtel, MD^,*

^* Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
Division of Cardiology, Albert Einstein College of Medicine, Bronx, New York, USA

Manuscript received October 24, 2003; revised manuscript received March 22, 2004, accepted March 30, 2004.

^* Reprint requests and correspondence: Dr. Thierry H. Le Jemtel, Department of Medicine, Division of Cardiology, Room G46, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York 10461, USA.
lejemtel{at}aecom.yu.edu

Patients with chronic heart failure (CHF) have a resting restrictive ventilatory defect. Any type of exercise requires patients with CHF to markedly increase their minute ventilation. Patients with chronic obstructive pulmonary disease (COPD) have airflow obstruction that leads to dynamic lung hyperinflation and reduced ventilatory response to exercise. Because exercise is associated with abnormally high minute ventilation in patients with CHF and with a limited minute ventilation increase in patients with COPD, functional capacity is severely impaired in patients with coexistent CHF and COPD. Optimal treatment of both conditions is a prerequisite to maximally improve functional capacity in patients with CHF and COPD. Unfortunately, beta-adrenergic blockade, the current cornerstone of CHF therapy, is frequently omitted in patients with CHF and COPD for fear of inducing bronchoconstriction. Furthermore, when prescribed, beta-adrenergic blockade is often attempted with a moderate dose of metoprolol tartrate, a beta-1-blocker that results in lesser clinical benefits than combined non-selective beta-blockade with carvedilol at the maximally recommended dose. Recent experience indicates that combined non-selective beta- and alpha-blockade with carvedilol is well tolerated in patients with COPD who do not have reversible airway obstruction. Alpha-adrenergic blockade may promote mild bronchodilation that offsets non-selective beta blockade-induced bronchoconstriction in patients with obstructive airway disease.

Abbreviations and Acronyms   CHF = chronic heart failure   CI = confidence interval   COPD = chronic obstructive pulmonary disease   DLCO = lung diffusing capacity for carbon monoxide   FEV1 = forced expiratory volume in 1 s   FVC = forced vital capacity   PaCO2 = partial arterial pressure of carbon dioxide   ROS = reactive oxygen species   VD/VT = ratio of physiologic dead space to tidal volume   WMD = weighted mean difference

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