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The waiting game

Inhalers linked to risk of heart attacks

By Nigel Praities

A controversial study suggests inhaled anticholinergics could substantially increase the risk of heart attacks and strokes in patients with COPD.

The meta-analysis by US and UK researchers found drugs such as tiotropium bromide raised the risk of cardiovascular death, heart attack, or stroke by as much as 58%.

But GP respiratory experts warned the study – published in JAMA - was ‘terribly flawed' amid claims that the publicity was causing patients to rush to A&E complaining of chest pain.

Overall 17 trials were included in the meta-analysis, which covered 14,700 patients followed for between six weeks and five years.

Researchers reported that risk of heart attack was increased by 53% and cardiovascular death by 80%. They also reported an increased risk in all cause-mortality but this did not reach significance.

The authors advised clinicians to closely monitor patients taking long-term anticholinergics for the development of cardiovascular events.

Study leader Dr Sonal Singh, instructor in internal medicine at Wake Forest University School of Medicine in the US, who led the research, said: ‘Clinicians should carefully consider these potential long-term cardiovascular risks of inhaled anticholinergics in treatment of COPD, and decide whether the risks are an acceptable trade-off for their symptomatic benefits.'

But UK respiratory experts insisted there was no need for GPs to change their practice.

Professor David Price, a GP in Norwich and professor of primary care respiratory medicine at the University of Aberdeen, heavily criticised the study, saying it contained too many confounders to be taken seriously. ‘It is terribly flawed and I am amazed it got into JAMA. Media reports have caused quite a problem, with patients turning up in emergency departments complaining of chest pain.'

Dr Dermot Ryan, a member of the General Practice Airways Group and a GP in Loughborough, Leicestershire said COPD was often undertreated and anticholinergics were proven to reduce exacerbations and improve quality of life. ‘I certainly wouldn't alter my treatment for people with COPD on the basis of these results,' he said.

Boehringer Ingelheim, manufacturer of the anticholinergic Spiriva, responded to media reports by releasing the results of a major study early.

UPLIFT compared outcomes with Spiriva versus placebo in nearly 6,000 patients with COPD, and found no increase in death, cardiovascular death or cardiovascular events.

The company said the fall-out from the JAMA study was causing ‘unnecessary panic' and comments from the researchers had been ‘irresponsible and misleading'.

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