People with asthma or chronic obstructive pulmonary disease (COPD) often depend on reliever inhalers when breathing suddenly becomes difficult.
But a large Belgian study suggests that using these inhalers too frequently may be a warning sign for more than poor lung control. Heavy use was linked to higher risks of cardiovascular disease and death, including heart failure, heart attack and ischemic stroke.
Reliever inhalers are designed to work quickly. They relax muscles around the airways, making it easier for air to move in and out of the lungs during periods of wheezing, coughing or breathlessness. Unlike maintenance or “preventer” treatments, however, their effects are short-lived and they do not necessarily control the underlying disease process.
Asthma is a long-term condition in which the airways can become inflamed and narrowed. COPD is another chronic lung disease, most often linked to smoking or long-term exposure to harmful particles, that makes airflow increasingly difficult. Although the two diseases are different, both can require quick-relief medicines when symptoms flare.
The new study examined real-world healthcare information from more than 280,000 people with asthma or COPD in Belgium. Researchers studied the use of two common types of short-acting bronchodilators: short-acting beta-agonists, known as SABAs, and short-acting muscarinic antagonists, known as SAMAs. Some patients used one type, some used both and others used neither.
The researchers adjusted their analysis for many factors that might affect the results. These included age, sex, smoking history, socioeconomic circumstances, disease severity, nursing home residence, other illnesses and use of other medicines. Even after these differences were considered, greater reliever use remained associated with poorer outcomes.
Among people with asthma, SABA use was associated with a 12% higher risk of death compared with no use. Among people with COPD, the increase was 14%. SAMA use showed an even larger association, with a 73% higher risk of death in asthma and a 36% higher risk in COPD.
The amount used also appeared to matter. Patients who went through three or more reliever inhalers in a year had a higher risk of death than those using two or fewer. The pattern suggested that risk continued to rise as annual inhaler use increased.
Researchers also found links with cardiovascular problems such as heart attack, heart failure and ischemic stroke, which occurs when blood flow to part of the brain is blocked. Interestingly, people without a previous history of cardiovascular disease appeared particularly vulnerable. This suggests that frequent reliever use could identify patients whose heart risk has not yet been recognized.
Professor Lies Lahousse of Ghent University and Erasmus MC Rotterdam said overuse is common, affecting almost one in five people with asthma and about one in three with COPD.
She described frequent reliever use as an alarm signal that the underlying lung condition may not be adequately controlled. In such cases, patients may need their treatment, inhaler technique and use of maintenance medicines reviewed.
There are several possible explanations for the findings. Poorly controlled asthma and COPD themselves are associated with inflammation, stress on the body and higher cardiovascular risk. At the same time, short-acting bronchodilators can cause side effects such as a faster or irregular heartbeat, potentially adding further strain in vulnerable patients.
This means the study cannot simply show that the inhalers themselves caused the heart problems. People who use more reliever medicine may already have more severe or poorly controlled lung disease, which could partly account for their higher risk. Although researchers adjusted for disease severity and many other factors, observational studies cannot completely remove this possibility.
The findings were published in ERJ Open Research. The research team now wants to investigate whether better use of maintenance treatment can reduce reliever overuse and whether cardiovascular risk checks could improve outcomes for people who frequently need these inhalers.
The study should not discourage patients from using a prescribed reliever inhaler when they need immediate help with breathing. Instead, repeated reliance on quick relief should prompt a conversation with a doctor, because it may indicate that long-term treatment needs improvement. Patients should not stop or change inhalers without professional advice.
Overall, the research provides a strong warning signal rather than proof that reliever inhalers directly cause cardiovascular disease. Its large size and clear dose-related pattern strengthen the concern, but the overlap between severe lung disease, inhaler use and heart risk makes cause and effect difficult to separate.
The practical message is that frequent reliever use deserves attention, because better control of asthma or COPD may protect both breathing and wider health.
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Source: Ghent University and Erasmus MC Rotterdam.
