Frequent Use of Rescue Inhalers May Signal Higher Heart and Mortality Risk

For people living with asthma or chronic obstructive pulmonary disease (COPD), short-acting inhalers can provide rapid relief when breathing becomes difficult. These medicines, commonly known as rescue or reliever inhalers, are an important part of respiratory care. However, new research suggests that frequent use of some short-acting bronchodilators may be associated with a greater risk of cardiovascular problems and death.

A large Belgian nationwide cohort study published as an early view article in ERJ Open Research examined the relationship between short-acting bronchodilator use, cardiovascular events and all-cause mortality in adults with asthma and COPD.

The study, led by Frauke Van Vaerenbergh and colleagues from Ghent University and Imperial College London, included more than 283,000 people. Researchers found that higher use of short-acting muscarinic antagonists (SAMA) and fixed-dose combinations containing a short-acting beta2-agonist (SABA) and SAMA was associated with increased risks of several cardiovascular outcomes and mortality.

The findings highlight an important message for patients and healthcare professionals: frequent reliance on rescue medication may be more than a symptom-control issue. It can also be a reason to reassess the underlying respiratory disease and overall cardiovascular health.

What are short-acting bronchodilators?

Short-acting bronchodilators work by relaxing the muscles around the airways, helping air move more easily into and out of the lungs.

SABAs, such as salbutamol, act on beta2 receptors and are widely used as quick-relief medicines. SAMAs, such as ipratropium, work through a different mechanism involving muscarinic receptors. Some inhalers combine the two types.

These medications can be useful when symptoms occur, but frequent reliance on short-acting treatment can indicate that asthma or COPD is not adequately controlled.

The researchers wanted to investigate whether repeated use of these medicines was also linked with cardiovascular events such as heart failure, arrhythmias, myocardial infarction and ischemic stroke.

A very large real-world study

The research examined Belgian healthcare data from 2017 through 2022. The cohort consisted of 226,314 adults with asthma and 57,446 adults with COPD.

The average age was approximately 58 years among people with asthma and 72 years among those with COPD. Cardiovascular disease was already common among the COPD group, with around 60% having a previous cardiovascular history.

Researchers measured short-acting bronchodilator exposure according to the number of standardized inhaler canisters collected during the baseline year. They divided patients into three broad categories: no use, one to two canisters, and three or more canisters.

The analysis also considered numerous other factors that could influence cardiovascular risk, including age, sex, smoking history, socioeconomic status, previous exacerbations, existing cardiovascular disease, diabetes, kidney disease, frailty and other medications.

What did researchers find?

One of the clearest findings involved SAMA-containing treatment.

Among both asthma and COPD patients, increasing use of SAMA and SABA plus SAMA combinations was generally associated with higher risks of cardiovascular outcomes and all-cause mortality.

For example, the study reported approximately 1.2 to 1.4 times higher risks of heart failure and around 1.1 to 1.4 times higher risks of arrhythmia among groups using SAMA or SABA plus SAMA, depending on the treatment and population examined.

Mortality risk was also higher, with estimates ranging from approximately 1.1 to 1.7 times the risk observed in the corresponding non-user groups.

Among people with asthma, frequent use of the SABA plus SAMA combination was associated with increased risks of myocardial infarction and ischemic stroke. In COPD, people collecting three or more combination canisters annually had a higher risk of myocardial infarction.

The results for SABA alone were somewhat different.

Patients collecting one or two SABA canisters per year did not show the same pattern of increased risk. In some analyses, this group actually had lower mortality or arrhythmia risk than people who did not collect SABA.

However, the picture changed among people collecting three or more SABA canisters per year. This level of use was associated with approximately 1.1 times higher risks of heart failure and mortality in both asthma and COPD.

The authors therefore emphasize that the amount and type of short-acting medication matter.

Why could rescue inhaler use be linked to heart problems?

There are several possible explanations, and the study does not prove that inhalers directly cause cardiovascular disease.

Both beta-adrenergic and muscarinic receptors are found in the cardiovascular system as well as the lungs. Beta-agonists can increase heart rate and lower blood potassium levels, changes that may contribute to cardiovascular stress in susceptible individuals.

Anticholinergic medicines can also influence cardiovascular function. The researchers suggest that cumulative anticholinergic exposure may be relevant, particularly among people with COPD or more severe respiratory disease who may already be taking several medications.

There is another important possibility: frequent rescue inhaler use may be a marker of poorly controlled or more severe respiratory disease.

Someone who repeatedly needs quick-relief medication may be experiencing frequent symptoms or exacerbations. Severe asthma and COPD themselves are associated with cardiovascular complications. Consequently, the relationship between inhaler use and cardiovascular outcomes may be influenced by the underlying severity of the patient's disease.

The researchers attempted to account for this by adjusting for exacerbation history and maintenance treatment, and the overall patterns remained.

The findings do not mean patients should stop their inhalers

This is perhaps the most important point for patients.

The study was observational. Researchers examined associations in healthcare data rather than assigning patients to different inhaler treatments in a randomized clinical trial.

Therefore, the results cannot establish that short-acting bronchodilators directly caused heart attacks, heart failure, strokes or deaths.

Patients should not stop prescribed inhalers because of this study.

Instead, frequent use should be viewed as a potential warning sign that deserves medical attention. If someone with asthma or COPD repeatedly needs their rescue inhaler, their healthcare professional may need to review symptom control, inhaler technique, maintenance treatment, exacerbation history and possible cardiovascular risk factors.

What could patients and clinicians take from the research?

The study supports a broader approach to respiratory care.

For asthma, current international treatment strategies have increasingly moved away from relying solely on SABA rescue treatment. Anti-inflammatory treatment is an important part of controlling the underlying disease, and the researchers note the changing role of SABA monotherapy in modern asthma management.

For COPD, frequent short-acting bronchodilator use may similarly prompt a review of maintenance therapy and disease control.

The researchers also suggest that cardiovascular risk deserves attention, particularly among patients who remain poorly controlled or frequently use short-acting medication.

This could involve reviewing blood pressure, cholesterol, diabetes, smoking status, previous cardiovascular disease and other relevant risk factors.

A useful signal, not a reason for panic

The key message from this large study is not that rescue inhalers are inherently dangerous. Rather, repeated reliance on short-acting bronchodilators may identify people who require closer clinical review.

Three or more SABA canisters per year was associated with increased mortality and heart failure risk in the study, while higher use of SAMA-containing therapies showed broader associations with cardiovascular outcomes and mortality.

For patients, that means frequent rescue inhaler use should not simply be accepted as normal.

If your reliever is becoming a regular part of daily life, speak with your doctor or respiratory healthcare professional. Better control of asthma or COPD may reduce the need for short-acting medication while also providing an opportunity to identify and manage other health risks.

The study ultimately reinforces a simple principle: effective respiratory care is not only about opening the airways when symptoms appear. It is also about understanding why symptoms are occurring so frequently and ensuring that the patient's overall health is being addressed.

Source

Van Vaerenbergh F, Vauterin D, Bloom C, Lahousse L. Cardiovascular effects and mortality of short-acting bronchodilators in asthma and COPD. ERJ Open Research. 2026, in press. DOI: 10.1183/23120541.00462-2026.

Disclaimer

This article is for general educational and informational purposes only. It is based on findings from an observational research study and does not establish that short-acting bronchodilators directly cause cardiovascular disease or death. The findings should not be interpreted as a recommendation to stop, reduce or change prescribed medication. Patients with asthma or COPD should discuss concerns about inhaler use, symptoms or cardiovascular risk with a qualified healthcare professional.