title: Tiotropium and risk for fatal and nonfatal cardiovascular events in patients with chronic obstructive pulmonary disease: systematic review with meta-analysis.
abstract: BACKGROUND
  There are safety concerns regarding the use of anticholinergics in the COPD patient population. The purpose of this review was to evaluate the cardiovascular risk of regular use of inhaled tiotropium bromide in patients with COPD of any severity.
  
  
  METHODS
  Systematic searches were conducted in MEDLINE, EMBASE, the Cochrane Controlled Trials Register, manufactures' trial register, and FDA databases, without language restriction. Primary outcomes were a composite of major adverse cardiovascular events, cardiovascular mortality, and nonfatal myocardial infarction (MI) or stroke during the treatment period. Relative risks (RR) were estimated using fixed-effects models and statistical heterogeneity was estimated with the I2 statistic.
  
  
  RESULTS
  Nineteen randomized controlled trials (18,111 participants) were selected. There was no difference in the incidence of adverse cardiovascular events (RR=0.96; 95% CI, 0.82-1.12, I2=6%). Among individual components of the composite outcome, tiotropium did not significantly increase the risk of cardiovascular death (RR=0.93; 95% CI, 0.73-1.20, I2=1%), nonfatal MI (RR=0.84; 95% CI, 0.64-1.09, I2=0%), and nonfatal stroke (RR=1.04; 95% CI, 0.78-1.39, I2=0%). A smoking history of > or = 55 pack-years presented a trend to a higher rate of cardiovascular adverse events in patients receiving tiotropium.
  
  
  CONCLUSIONS
  Compared with control (placebo or salmeterol), tiotropium did not significantly increase the risk of adverse major cardiovascular events among COPD patients. Subgroup analysis suggested that smoking history can modify the risk of cardiovascular adverse events.
authors: Departamento de Emergencia, Hospital Central de las Fuerzas Armadas, Av. 8 de Octubre 3020, Montevideo 11600, Uruguay. gurodrig@adinet.com.uy
authors: Gustavo J
authors: GJ
authors: Rodrigo
authors: José A
authors: JA
authors: Castro-Rodriguez
authors: Luís J
authors: LJ
authors: Nannini
authors: Vicente
authors: V
authors: Plaza Moral
authors: Eduardo A
authors: EA
authors: Schiavi
mesh_terms: D000280:Administration, Inhalation; D001993:Bronchodilator Agents / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D009203:Myocardial Infarction / Q000139:chemically induced* / Q000401:mortality; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy* / Q000401:mortality; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012602:Scopolamine Derivatives / Q000008:administration & dosage / Q000009:adverse effects*; D020521:Stroke / Q000139:chemically induced* / Q000401:mortality; D000069447:Tiotropium Bromide
chemical_list: D001993:Bronchodilator Agents; D012602:Scopolamine Derivatives; D000069447:Tiotropium Bromide