Preventing Adverse Cardiac Events in COPD

Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of global health-related morbidity and mortality. Heart disease in COPD is a known but neglected comorbidity and cardiovascular disease (CVD) accounts for 30-50% of deaths in COPD participants. Studies repeatedly show that CVD in COPD participants is under-recognised and under-treated yet participants with COPD are frequently excluded from clinical trials of drugs which reduce cardiac morbidity and mortality. This has led to under-treatment of CVD in COPD participants. A particular concern is low use of β-blockers. These have previously been considered to be contra-indicated in COPD and no RCTs have been conducted in this population. There is now observational evidence that cardioselective β-blockers are safe and may improve mortality, but this data is limited to retrospective analyses of cohorts of COPD participants. Contrary to previous concerns, retrospective analyses also suggest that cardioselective β-blockers may reduce the risk of COPD exacerbations. The proposed study will focus on treating CVD in COPD participants to reduce mortality and morbidity.

The study will be conducted in 23 sites in Australia, New Zealand, India and Sri Lanka. Participants with COPD will be randomised to one of two treatment arms in addition to receiving usual care for their COPD over the study duration of 24 months.

Inclusion criteria

Participants will be eligible for this study if they qualify on all of the following:

• Have provided written informed consent
• Have COPD defined by the 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) diagnostic criteria
• Aged 40-85 years
• FEV1 ≥30% and ≤70% predicted post-bronchodilator
• FEV1/FVC <0.7 post-bronchodilator
• Have had a COPD exacerbation in the previous 24 months requiring oral corticosteroid, antibiotics, or both
• If taking maintenance OCS, dosage is stable and ≤10mg daily for 4 weeks prior to randomisation
• Resting SBP ≥100mmHg
• SBP and spirometry criteria must be met after the test dose of bisoprolol of 1.25mg
• (New Zealand only) A history of cardiovascular disease, including heart failure, ischaemic heart disease, tachyarrhythmias, and hypertension

Exclusion criteria

Participants will be ineligible for the study if they have any of the following:

• Concurrent therapy with any other β-blocker
• Resting HR <60bpm
• Unstable left HF (i.e. symptomatic and/or necessary change in management in the last 12 weeks, or in clinicians' opinion)
• Clinically significant pulmonary hypertension, which in the investigator's opinion would be a contraindication for β-blocker therapy
• Severe end-stage peripheral vascular disease
• 2nd or 3rd degree heart block
• Currently using or have been prescribed LTOT or resting saturated oxygen level <90% when stable
• Expected survival is less than 12 months, or in the investigator's opinion, the person has such unstable disease (of any type) that maintaining 12 months' participation would be unlikely
• Clinical instability since a MACE in the previous 12 weeks
• Lower respiratory tract infection or AECOPD within the last 8 weeks
• COPD not clinically stable as determined by the investigator
• In the clinician's view, have asthma-COPD overlap or co-existent asthma are present; or an improvement in FEV1 ≥400mL post-bronchodilator is observed on two occasions
• Females of child-bearing age and capability who are pregnant or breastfeeding or those in this group not using adequate birth control
• Coexistent illness which precludes participation in the study (poorly controlled diabetes, active malignancy)
• Severe end-stage liver disease defined by INR>1.3 and albumin<30g/L or portal hypertension/ascites
• High chance in the view of the treating physician that the potential participant will not adhere to study requirements