Should Beta Agonists Be Withheld From Some Dyspnea Patients?
Should Beta Agonists Be Withheld From Some Dyspnea Patients?
In patients with dyspnea, prehospital and emergency providers make therapeutic decisions before a diagnosis is established. Inhaled beta-2 agonists are frontline treatment for patients with dyspnea due to asthma or chronic obstructive pulmonary disease (COPD) exacerbations. However, these agents have been associated with increased adverse events when administered chronically to heart failure patients. Our goal was to determine the safety and efficacy of acute administration of inhaled beta-2 agonists to patients with heart failure. MEDLINE and EMBASE searches were performed using the terms "beta agonists," "albuterol," "congestive heart failure," and "pulmonary edema." Bibliographies of relevant articles were searched. Only studies addressing acute effects of beta-2 agonists were included for analysis. Twenty-four studies comprising 434 patients were identified that addressed the acute delivery of beta-2 agonists in subjects with heart failure—five studies with inhaled administration and 19 with systemic administration. No study directly evaluated the effects of inhaled beta-2 agonists to patients with acutely decompensated heart failure. Treatment of heart failure patients with beta-2 agonists resulted in transient improvements in pulmonary function and cardiovascular hemodynamics. Only one investigation reported an association between beta-2 agonist use and an increase in malignant dysrhythmias. Investigations in animal models of heart failure and acute lung injury demonstrated resolution of pulmonary edema with beta agonist administration. There is insufficient evidence to suggest that acute treatment with inhaled beta-2 agonists should be avoided in patients with dyspnea who may have heart failure. Based on small studies and indirect evidence, administration of beta-2 agonists to patients with heart failure seems to improve pulmonary function, cardiovascular hemodynamics, and resorption of pulmonary edema. Although an increase in adverse effects with the use of beta-2 agonists cannot be ruled out based on these data, there was no evidence of an increase in clinically significant dysrhythmias, especially when administered by inhalation. Based on these findings, further study should focus on the clinical outcomes of patients with acutely decompensated heart failure who are treated with inhaled beta-2 agonist therapy.
Acutely decompensated heart failure (ADHF) is a common condition that resulted in 10.5 million Emergency Department (ED) visits between 1992 and 2001, representing 2.9% of all ED visits over that same time period. This clinical syndrome is characterized by the development of dyspnea associated with the rapid accumulation of interstitial and alveolar fluid as a result of elevated cardiac filling pressures.
Treatment of ADHF is often required before a definitive diagnosis can be established with further testing in both the prehospital and ED settings. Causes of dyspnea that overlap with the presentation of ADHF include acute pulmonary processes such as chronic obstructive pulmonary disease (COPD) exacerbation. Although treatment with inhaled beta-2 agonists such as albuterol (salbutamol outside the United States) is accepted therapy for patients presenting with dyspnea due to an asthma flare or COPD exacerbation, practitioners in the prehospital, urgent care, and ED settings may have concerns about the use of these agents when heart failure or myocardial ischemia are possible or likely.
There is a significant body of evidence that, administered chronically to patients with heart failure, beta-2 adrenoceptor agonists are associated with an increased risk of adverse events, including dysrhythmias, hospitalization for heart failure exacerbations, and an increase in all-cause mortality. In fact, current standards recommend chronic treatment with selective beta blockade for patients with stable heart failure. Whether the same adverse outcomes seen with chronic administration of beta-2 agonists are associated with the acute administration of beta-2 agonists is unclear, and beta blockade is contraindicated in patients with ADHF. The objective of this review is to determine whether the evidence supports or refutes the administration of beta 2-adrenoceptor agonists to patients with heart failure in the acute setting. Specifically, we sought to determine the effects of these agents on: 1) pulmonary function, 2) cardiovascular hemodynamics, and 3) adverse events, particularly worsening of cardiac ischemia or induction of malignant dysrhythmias.
Abstract and Introduction
Abstract
In patients with dyspnea, prehospital and emergency providers make therapeutic decisions before a diagnosis is established. Inhaled beta-2 agonists are frontline treatment for patients with dyspnea due to asthma or chronic obstructive pulmonary disease (COPD) exacerbations. However, these agents have been associated with increased adverse events when administered chronically to heart failure patients. Our goal was to determine the safety and efficacy of acute administration of inhaled beta-2 agonists to patients with heart failure. MEDLINE and EMBASE searches were performed using the terms "beta agonists," "albuterol," "congestive heart failure," and "pulmonary edema." Bibliographies of relevant articles were searched. Only studies addressing acute effects of beta-2 agonists were included for analysis. Twenty-four studies comprising 434 patients were identified that addressed the acute delivery of beta-2 agonists in subjects with heart failure—five studies with inhaled administration and 19 with systemic administration. No study directly evaluated the effects of inhaled beta-2 agonists to patients with acutely decompensated heart failure. Treatment of heart failure patients with beta-2 agonists resulted in transient improvements in pulmonary function and cardiovascular hemodynamics. Only one investigation reported an association between beta-2 agonist use and an increase in malignant dysrhythmias. Investigations in animal models of heart failure and acute lung injury demonstrated resolution of pulmonary edema with beta agonist administration. There is insufficient evidence to suggest that acute treatment with inhaled beta-2 agonists should be avoided in patients with dyspnea who may have heart failure. Based on small studies and indirect evidence, administration of beta-2 agonists to patients with heart failure seems to improve pulmonary function, cardiovascular hemodynamics, and resorption of pulmonary edema. Although an increase in adverse effects with the use of beta-2 agonists cannot be ruled out based on these data, there was no evidence of an increase in clinically significant dysrhythmias, especially when administered by inhalation. Based on these findings, further study should focus on the clinical outcomes of patients with acutely decompensated heart failure who are treated with inhaled beta-2 agonist therapy.
Introduction
Acutely decompensated heart failure (ADHF) is a common condition that resulted in 10.5 million Emergency Department (ED) visits between 1992 and 2001, representing 2.9% of all ED visits over that same time period. This clinical syndrome is characterized by the development of dyspnea associated with the rapid accumulation of interstitial and alveolar fluid as a result of elevated cardiac filling pressures.
Treatment of ADHF is often required before a definitive diagnosis can be established with further testing in both the prehospital and ED settings. Causes of dyspnea that overlap with the presentation of ADHF include acute pulmonary processes such as chronic obstructive pulmonary disease (COPD) exacerbation. Although treatment with inhaled beta-2 agonists such as albuterol (salbutamol outside the United States) is accepted therapy for patients presenting with dyspnea due to an asthma flare or COPD exacerbation, practitioners in the prehospital, urgent care, and ED settings may have concerns about the use of these agents when heart failure or myocardial ischemia are possible or likely.
There is a significant body of evidence that, administered chronically to patients with heart failure, beta-2 adrenoceptor agonists are associated with an increased risk of adverse events, including dysrhythmias, hospitalization for heart failure exacerbations, and an increase in all-cause mortality. In fact, current standards recommend chronic treatment with selective beta blockade for patients with stable heart failure. Whether the same adverse outcomes seen with chronic administration of beta-2 agonists are associated with the acute administration of beta-2 agonists is unclear, and beta blockade is contraindicated in patients with ADHF. The objective of this review is to determine whether the evidence supports or refutes the administration of beta 2-adrenoceptor agonists to patients with heart failure in the acute setting. Specifically, we sought to determine the effects of these agents on: 1) pulmonary function, 2) cardiovascular hemodynamics, and 3) adverse events, particularly worsening of cardiac ischemia or induction of malignant dysrhythmias.
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