Beta Blockers and Pulmonary Edema Risk

[jsex]

I posted the following text on Facebook recently and thought it should have a wider audience and open it for comments from the people who frequent this board. I am very interested in hearing what folks like Dr Deco have to say...

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I received a scary message from an diving friend recently. One that sent chills down my spine and thoughts racing through my brain. It sent me on a journey of online research and turned up some quite unclear and often contradictory information. What it did give me was a decided feeling of how little we know about drugs and diving and how deadly that lack of knowledge can be.



As you know, I like to hang out in and around the water. Due to that addiction to water environments, I like to stay up to date on many things from new sailing or dive gear to medical information and treatments that have to do with diving. Pretty much anything really. After my recent re-posting of @MMVittone great article about "Drowning doesn't look like drowning" Drowning Doesn?t Look Like Drowning , my friend wrote me a PM and related his short story that started everything rolling. (disclaimer:names may have been changed to protect the not too innocent)



In short..." almost died from pulmonary edema. The physician feels it happened because I was on a beta blocker. He has seen 7 similar cases in two years. (emphasis is mine just so this number sticks with you-jsex) A very good dive operation and medical clinic pulled me through. The observation is by the well known hyperbaric physician in Coz--Dr. Pascuale Piccolo--he first saw it in a 30 year old free diver on a beta blocker for blood pressure. One of the staff said they had seen this happen to someone about my age (62) a month ago--also on a beta blocker. According to Dr. Piccolo, DAN has been reluctant to acknowledge his observations."



So, here was a commonly prescribed class of drugs that thousands, if not millions, of people use daily to control blood pressure around the world. And it possibly has unforeseen consequences when coupled to diving (and thus pressure changes but more on that later). This caused me some worry as I had not heard of this supposed interplay and off I went, killing many hours of my time trying to find some clear evidence of just what was happening. And it was not there...



So, I asked people involved with diving and hyperbaric medicine what they had seen, heard or experienced. Only one of some 200 instructors that I contacted in Pms had even heard of beta blockers and diving as contra-indicative. And he had heard it only in relation to free diving, not scuba. And one doctor, involved with my diving insurance company Aquamed aqua med | Medizinischer Tauchernotruf ? Assistance ? Tauchunfallversicherung - Reisemedizin | Startseite and diving medicine, Dr. Anke Fabian, did offer some guidance when I asked her about her take on this...



In short, our conversation went like this...

me, “have you seen incidence of pulmonary edema related to beta blockers and diving?”



Anke, “yes - I have seen this many times especially in divers above 45 years .

Therefore: we don't recommend diving on Betablockers in the second half of life”



me, “Anke, another question if I may. Do you know of anyone who may be doing research into this? I was wondering if there were any markers or such when this was happening. As in, is the onset gradual so that if noticed by a trained dive pro, the diver could be warned and stop diving before things got bad?”



Anke, “don't know any research about it

the first signs are heavy breathing under water with the feeling not to get enough oxygen. If you have a diver who is on betablocker medication and older than 35 years - start a controlled ascent when observing these symptoms.

Basically heavy breathing is a non specific symptom and can be caused by a million of things - but in divers on betablockers - it would make me alert”



Ok, I asked her two questions there, so sue me...But there is take home information here that you need to know and act on!



Dive professionals, this is a new and very necessary bit of info you need to ask your diving charges--->are you on beta blockers?



And this is something extra for you to watch--->heavy breathing in the group on beta blockers.



And I would guess this would need to be both before, during and after dives for reference and trigger-to-action. And when triggered, follow Anke's instructions about a controlled ascent...



Interestingly, the instructors I questioned almost all commented on the medical form that students fill in when they take diving lessons. It was mentioned that if any of the answers comes up Yes, then a diving doctor should be consulted. What none of them commented about was what I think would be/is a pretty common situation, someone who already has a diving certificate and later in life starts taking beta blockers. If the prescribing doctor is not a diver, a diving doctor and/or is not aware his charge is a diver, the disconnect could be fatal.



Now, I am not saying that we should alarm everyone. I am just saying that there needs to be a level of caution which is a bit higher than what we see concerning this particular subject. I, for one, could have been using beta blockers for years to control high blood pressure had I not found alternative methods to remain calm and deal with it...drop out of the rat race, change diet and eat healthy, meditation just to name a few that I practice. But if you can't do any, some or all of these or other alternatives, you might want to suspend any diving activities if you are taking beta blockers until more is known or you are off of them.



In an added twist to the incident story of my friend, he just mentioned this in passing! "think we need more awareness of the potential problems that they can cause. When I noted on my dive accident report that I was coughing at depth, the nurse (who is Dr. Piccolo's wife) ask how long I had noticed that I coughed at depth. I said, "about 10 years" and she asked "How long have you been on beta blockers?" "About 10 years. And I thought it was just my allergies and usual sinus crud."

And last but not least dive pros, you need to ask something like this, "Do you need to cough at depth?"

And using my logic (yes folks) I am thinking that this is probably not dry air exposure to the lungs which is causing the edemas but pressure differences/changes. Make sense to you? It happens in free divers as well as scuba, so the only real common factor that I am seeing here is pressure differences/changes. So, what does this have to do with real life? I am wondering how flying affects beta blocker users now as well!

 

[flots am]

Scuba Diving with Beta-Blockers for High Blood Pressure ? Medical Dive Article ? DAN | Divers Alert Network

Beta blockers aren't recommended for SCUBA, since they can cause loss of consciousness underwater.

 

[AfterDark]

I took that poison for about 2 months but had to stop because of severe cramps, thankfully. MD had me try several other meds for my BP all had some kind of adverse affect on me. Finally told the MD to keep his meds and his practice, that was 8 years ago. My BP has gone down since I stopped going to the MD and taking that crap. IMO all just a big scam, a harmful one at that. Haven't been to an MD since. Next medical type that sees me will be the coroner.

That is except for the orthopedic types, I keep tearing tendons.

 

[TSandM]

The phenomenon of immersion pulmonary edema is not well understood, and is under active study. Cases have been recorded in young, healthy athletes on no medications, as well as in older divers on various medications.

Beta blockers are EXTENSIVELY prescribed for hypertension and for coronary artery disease. There may be a subgroup of patients on beta blockers who are at elevated risk for IPE, but we don't know who those patients are. To tell the entire universe of diving that no one on beta blockers should dive is not justified by the currently available evidence.

 

[Duke Dive Medicine]

I concur with TSandM. I think that blanket statements like "don't dive on beta blockers" are ill-advised. When addressing the issue of medications and diving, the first question we always ask is, "Why are you on the medication?" Beta blockers, for example, are not generally the first-line drugs for treatment of hypertension. Therefore, it's possible that someone who is taking beta blockers has an underlying medical condition that could make him or her more susceptible to pulmonary edema. So, if pulmonary edema happens, is the beta blocker to blame or is it the individual's medical condition? I'd also add that true IPE, or immersion pulmonary edema, should be differentiated from pulmonary edema that occurs while immersed.

If you are on a medication and have a question as to whether or not you should dive, the best advice is to be evaluated by a trained diving medical practitioner.

Best regards,
DDM

 

[TSandM]

Yes, it is important to remember that correlation does not imply causation; that is precisely why we do controlled trials to test hypotheses. If IPE and beta blocker use are correlated, is it because of the medication, or because of the patient's underlying physiology which occasioned the beta blocker in the first place? Are the beta blocker-using patients also patients with diastolic dysfunction, predisposing them to higher PA pressures when volume centralizes? We just don't know the answers, but people are actively seeking them.

I find it very unfortunate when people make emotional, blanket recommendations based on poor and anecdotal evidence. I would be willing to be that EVERY patient who has had IPE has drunk milk at some point in their lives -- I would not, however, recommend that anyone who drinks milk stop diving.

 

[DocVikingo]

Hi jsex,

I fully concur with TSandM & DDM.

I didn't spend time digging up the most current stats, but >191.5 million prescriptions for beta-blockers were filled in 2010 & I suspect that number has increased over the last couple of years. Based on this figure alone, one much suspects that a meaningful subset of these prescriptions went to persons who dive. Yet, while there are decent non-IPE related reasons to be circumspect regarding their use in divers, there is to date no published research indicating that beta-blockers pose a substantial risk of IPE in divers.

I have been acquainted with Dr. Piccolo for many, many years and indeed he is a well-known, and generally, although not universally, well-regarded hyperbaric physician in CZM. However, he is not of the same standard of training and experience as the majority of the diving medicine specialists associated with DAN, and if DAN has been “reluctant to acknowledge his observations," I believe there is sound reason for this hesitancy. Clinical intuition based a handful cases over decades does not substitute for real research. As far as I know, DAN has no proprietary interest in the promotion of beta-blockers and believe that they would take a relatively strong position against their use by divers if they were solidly linked to IPE by respectability done and published research. In this regard, I think that both Dr. Piccolo and interested readers of this thread would be well served to appreciate DDM’s statement that, “Beta blockers, for example, are not generally the first-line drugs for treatment of hypertension. Therefore, it's possible that someone who is taking beta blockers has an underlying medical condition that could make him or her more susceptible to pulmonary edema. So, if pulmonary edema happens, is the beta blocker to blame or is it the individual's medical condition? I'd also add that true IPE, or immersion pulmonary edema, should be differentiated from pulmonary edema that occurs while immersed.”

As apparently do the other doctors so far involved in this discussion, I think that rambling and ill-considered conjecture regarding the possible association between beta-blockers and IPE may unnecessarily upset divers who are taking them when such speculation is greatly premature. At this point in time, otherwise healthy divers have no basis for concern under normal circumstances. If I were put on a beta-blocker for uncomplicated hypertension, found my exercise tolerance to remain acceptable and didn't experience any other features worrisome to diving, I wouldn’t for a minute hesitate to engage in reasonable recreational scuba. Such anecdotal material as you have presented here most definitely would not send “chills down my spine and thoughts racing through my brain.”

Regards,

DocVikingo

 

[jsex]

Great info TSandM, DDM and DocVikingo. This is exactly why I brought this discussion here. I too do not want to scare people unnecessarily as I think everyone should be diving when and if possible. I will borrow some of your points stated in this discussion to put forward in other venues, with your permission... Also, I am not diferentiating between IPEs and PE while immersed...beyond my scope of knowledge...

For the record, I am not a medical expert, only your average diving bum that has worked in the industry or been associated to it for around 42 years now. I feel that there is caution to be given to the combination of Betas and diving based on what I have heard. From the articles I have read since my friend talked with me, I am aware that some people seem to have a predisposition to PEs. Until there is a way to know who is and who isn't, diving and betas should be avoided in my opinion. My diving medical insurance is via a German organization which does advise against betas and diving in the 2nd half of your life...

When I hear that diving doctors in the field, Dr Picolo in Coz and Dr Fabian in Sharm, are noting a possible trend/correlation, and lacking info because research has not proven that we should avoid the combination, I think that a bit of caution is not a bad thing.

I can only say that if I were prescribed Betas, I would either not take them, deal with my high blood pressure in another way and continue diving or take the meds and not dive pending more research info.

 

[DocVikingo]

... I am not diferentiating between IPEs and PE while immersed--beyond my scope of knowledge...; I think that a bit of caution is not a bad thing...; I can only say that if I were prescribed Betas, I would either not take them, deal with my high blood pressure in another way and continue diving or take the meds and not dive pending more research info.

Hi jsex,

I agree that a bit caution is not a bad thing, but think that near hysteria over the issue is.

Happily, control of hypertension has a veritable luxury of treatment possibilities. Along with the customary & healthful behavioral approaches (e.g., smoking cessation, weight reduction, regular exercise, salt restriction, stress management, going easy on alcoholic beverages), there is a huge number of choices of medications aside from beta-blockers that may be considered, including diuretics, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha blockers, alpha-2 receptor agonists, peripheral adrenergic inhibitors and vasodilators, some of which can be used in combination. While most divers tolerate moderate doses of beta-blockers well, DAN recommends ACE (angiotensin converting enzyme) as the preferred class of drug for treating hypertensive divers (e.g., benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestri), ramipril (Altace)).

I’d like DDM to speak to the IPE v PE distinction he intends, but my take on his remark is that one should differentiate between PE that has immersion as its primary cause versus PE that has another primary cause, but just happens to occur while the individual is submerged (e.g., cardiac arrhythmia, fluid overload secondary to kidney dysfunction, upper airway obstruction, aspiration of seawater or gastric fluid, pulmonary contusion).

Regards,

DocVikingo

 

[kwinter]

I found it incredibly interesting. I am on beta blockers for the past 6 months, but not for hypertension. I developed post-operative a-fib and also tend to throw a lot of PVCs. In general, I have a somewhat irritable heart. My cardiologist put me on the beta blocker while things cleared up and has been fighting my desire to get off it because she thinks it is having a good effect on my heart function. Here's the kicker. She knows I'm a diver, knows some diving medicine, and used to work with Fred Bove, author of Diving Medicine and the physician quoted in the DAN article. So why is she insisting that I stay on it and not concerned at all about my tech diving?