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To the Editor: The meta-analysis of inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease (COPD) by Dr Singh and colleagues¹ successfully collected unpublished data and combined it with published studies. However, a 4-year randomized controlled trial involving 5993 patients (Understanding Potential Long-term Impacts on Function With Tiotropium [UPLIFT])² that was published shortly after this meta-analysis showed no evidence of an increased risk of cardiovascular adverse events with the use of tiotropium. One possible explanation that should be considered for this discordance is publication bias, as might be suggested by a funnel plot.

I am also concerned that there may be errors in data entry and study inclusion in the meta-analysis. The incidence of serious cardiovascular events in the study by Wedzicha et al³ appears to have been 34 in the tiotropium group and 23 in the placebo group; the study by Singh . . . [Full Text of this Article]

Yuji Oba, MD
obay@health.missouri.edu
Department of Pulmonary, Critical Care,  and Environmental Medicine
University of Missouri
Columbia

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