Is the use of beta-blockers in COPD still an unresolved dilemma?

Beta-blockers are competitive antagonists at beta-adrenergic receptors (beta-AR) and are a life-saving form of treatment in different cardiovascular diseases (CVD). Despite current guidelines supporting the use of selective beta(1)-blockers in patients with CVD and especially in heart failure (HF), they are still largely underused, mostly as a consequence of the presence of chronic obstructive pulmonary disease (COPD). In primary care, prevalence of COPD in patients with HF is approximately 25%, and it will rise in the next years. In the general population, only 20% of COPD patients with HF are treated with beta-blockers. beta-Blockers may result in pulmonary adverse effects that are relevant to COPD patients. Bronchoconstriction may be the consequence of: absence of cardioselectivity; loss of cardioselectivity at high doses, and unopposed stimulation of cholinergic muscarinic M(2) receptors. The concern of inducing bronchospasm is the more likely explanation of a poor prescription of beta-blockers in patients with CVD also suffering from COPD. However, under carefully controlled conditions, which include close monitoring of lung function and appropriate selection of the drug and titration of the dose on a case-by-case basis, selective beta(1)-blockers can be safely administered to most patients with COPD. Pneumologists and cardiologists should develop a detailed and standardized protocol to guide the use of selective beta(1)-blockers in everyday practice, which could significantly reduce the physicians' mistrust of beta-blockers in COPD patients.