Case: A 55-Year-Old Man With Asthma Presents to the ED With Dyspnea at Rest

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A middle-aged man with asthma, hypertension, and hyperlipidemia presents to the ED with dyspnea at rest.
A middle-aged man with asthma, hypertension, and hyperlipidemia presents to the ED with dyspnea at rest.


Answer: B. Metoprolol succinate

Discussion

In patients with asthma or chronic obstructive pulmonary disease, the use of non-selective beta-blockers may precipitate bronchospasm and thus worsen their pulmonary disease. Propranolol is a non-selective beta-blocker and would be contraindicated in this patient with asthma. Atenolol and metoprolol are both beta-1 selective beta-blockers and could be used in a patient with asthma; however, this patient also has systolic heart failure. Therefore, metoprolol succinate would be the best choice because it is the only beta-1 selective beta-blocker on the list that has been shown to improve mortality in patients with congestive heart failure.

In a meta-analysis of randomized controlled trials, Salpeter et al found that long term beta-blockade did not increase the risk for worsening respiratory symptoms or increase the use of inhaled beta-agonists.1 Although the available data are limited, some studies suggest that drugs such as labetalol or carvedilol, which are non-selective beta-blockers, combined with an alpha-blocker may be safe in patients with mild to moderate chronic obstructive pulmonary disease.2 

Nonetheless, regardless of the chosen beta-blocker, great care and caution should be taken when prescribing beta-blockers to patients with pulmonary disease. If dyspnea worsens, requiring more medication to control symptoms or if exercise intolerance or a cough develop, the patient should be reevaluated.

References

  1. Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective β-blockers in patients with reactive airway disease: a meta-analysis. Ann Intern Med. 2002;137(9):715-725.
  2. Guazzi M, Agostoni P, Matturri M, Pontone G, Guazzi MD. Pulmonary function, cardiac function, and exercise capacity in a follow-up of patients with congestive heart failure treated with carvedilol. Am Heart J. 1999;138(3):460-467.
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