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BMJ 2008; 337 doi: (Published 30 September 2008) Cite this as: BMJ 2008;337:a1854

Anticholinergics linked to extra deaths and heart attacks in COPD

Inhaled anticholinergic drugs reduce the breathlessness associated with chronic obstructive pulmonary disease (COPD), help prevent exacerbations, and improve patients’ quality of life. A meta-analysis of 17 randomised trials now reports that the two commonly used agents also increase the risk of a serious cardiovascular event, including death, by an estimated 58% (1.8% v 1.2% for control; relative risk 1.58, 95% CI 1.21 to 2.06). The analysis included 14 783 men and women.

Patients treated with ipratropium or tiotropium for at least a month were more likely than controls to have a heart attack (1.53, 1.05 to 2.23) and to die of cardiovascular disease (1.80, 1.17 to 2.77). The authors found one extra death from cardiovascular disease for every 40 (18 to 185) patients treated for a year and one extra heart attack for every 174 (75 to 1835) patients treated. Controls had a placebo, inhaled β agonists such as salmeterol, or a combination inhaler containing a β agonist and a corticosteroid. Anticholinergics did not increase the risk of stroke or all cause mortality in this analysis.

Patients with chronic obstructive pulmonary disease already have a high risk of cardiovascular events, say the authors. Doctors and patients must decide if the extra risk associated with these agents is an acceptable trade off for improved symptoms.

Report estimates 16 million injecting drug users worldwide, three million with HIV

Nearly 16 million (15.9 million, range 11.0-21.2 million) people worldwide are injecting drug users, according to the latest estimates. Around 3 million (0.8-6.6 million) of them are HIV positive. China, Russia, and the US have the greatest numbers of injecting drug users, partly because they are among the most populous countries in the world. The prevalence of HIV in users is more than 10% in both China and the US. The prevalence in Russia is estimated at 37%. This figure rises to …

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