Patients with COPD who are talking anticholinergic inhalers to control their symptoms are at an increased risk of cardiovascular disease (CVD), a joint US and UK study has found.

Inhaled anticholinergics are currently recommended by NICE if smoking cessation and beta-2 agonists have failed to relieve breathlessness.

Last year, more than two million prescriptions were made for anticholinergic inhalers in England alone. For this latest study, the researchers conducted a meta-analysis of 17 randomised controlled trials involving 14,738 patients with COPD who had reported cardiac events.

In the studies, patients were assigned to receive treatment with inhaled anticholinergics, either ipratropium bromide or tiotropium bromide, an active control or a placebo inhaler. Study follow-up ranged from six weeks to five years.

Overall, they found that those using inhaled anticholinergics increased their risk of CVD, stroke and heart attacks by 58 per cent compared with pat-ients not on anticholinergics.

The risk of CVD appeared greater with long-term anticholinergic use, over six months, than with short-term use.

Study researcher Dr Yoon Loke, from the University of East Anglia, said: 'GPs should assess their patient's cardiac risks before prescribing anticholinergic inhalers.

'If the patient still prefers to have an anticholinergic inhaler, then I would try to minimise the treatment duration.'

In any case, the long-term benefits of these inhalers have yet to be proven, said Dr Yoon.

Guidelines should be updated so that GPs and patients can make a fully informed decision, he added.

sanjay.tanday@haymarket.com

JAMA 2008; 300: 1,439-50

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