Administration Of Beta-blockers Research Articles

베타차단제 복용에 따른 관상동맥질환자의 운동자각도 처방이 운동강도와 안정성에 미치는 영향

The purpose of this study is to investigate effects of rating of perceived exertion (RPE) of patients with coronary artery diseases based on beta blocker administration on exercise intensity and safety. The subjects of this study were patients with coronary artery diseases undergoing medical intervention procedure, who were divided into those who were administered of beta blockers (group A, n=41) and who were not (group B, n=42). They were conducted of exercise stress test, for measuring the HR, the VO2, and RER based on the RPE. The results of this study showed that %HR showed no difference between group A and group B in %HRmax, %VO2max, and %RERmax, when the RPE was 11 (somewhat). The %VO2 was significantly higher in group A than group B (p.05). The RER showed no difference between group A and B. When the RPE was 13 (some hard), the %HR and the %VO2 were significantly higher in group B than A, respectively (p.05). There was no difference in the %RER between the two groups. When the RPE was 15 (hard), the %HR, the %VO2, and the %RER were significantly higher in group B than group A, respectively (p.05). As for the percentage based on the HRR 85% as safety limit of exercise intensity, the exercise intensity showed no difference between A and B when the RPE was 11, while A (82.4±8.3%, 94.0±7.2 %) was significantly higher than B (86.5 ±8.3%, 98.5±5.3%) when the RPE was 13 and 15, respectively (p .05). As for the percentage based on the VO2R85% as safety limit of exercise intensity, the exercise intensity was significantly higher in group B (70.7± 11.1%, 85.7±9.4%) than A (63.4±12.3%, 78.9±10.1%) when the RPE was 13 and 15, respectively (p.05). Conclusively, the RPE 11 was appropriate both for group A and B in the effective limit, but the patients of group A may be recommended to be around 16 scales of the RPE safety limit and those of group B may be recommended to be 15 scales of the RPE.

Women and the management of acute coronary syndrome

Coronary heart disease (CHD) is the leading cause of morbidity and mortality in both men and women in the developed countries. Despite this fact, females are still under-represented in the majority of clinical trials. At the present time, only limited evidence is available with respect to the female-specific aspects of pathogenesis, management, and outcomes in acute coronary syndrome (ACS). Women less frequently undergo coronary intervention, and a lower proportion of women receive evidence-based pharmacotherapy, compared with men. It has been shown that women benefit from an invasive approach and coronary intervention in ACS as much as men, despite their advanced age and higher rate of bleeding complications. Also, administration of beta-blockers, ACE-inhibitors, and intensive statin therapy is associated with a comparable reduction of cardiovascular event rates in women and men. On the other hand, women may profit less than men from fibrinolytic or glycoprotein IIb/IIIa inhibitor therapy. Both sexes benefit equally from aspirin therapy, whereas contradictory data are available on the efficacy of clopidogrel in women. There is an urgent need for intensive research in the development of female-specific therapeutic strategy in ACS, even though the detailed mechanisms of sex differences are still unknown.

Developing strategies for predicting and preventing readmissions in vascular surgery

The escalating cost burden of hospital readmission has prompted recent nationwide efforts aimed at reducing the incidence of this important quality measure. Because patients undergoing vascular surgery account for a significant proportion of readmissions, vascular surgeons may face reduced reimbursements in the near future if these trends continue. However, risk factors associated with readmission remain poorly defined, and further research is needed to identify interventions that will prevent readmission following vascular procedures. Accordingly, this manuscript will (1) propose a conceptual model to explain the driving forces behind readmissions in vascular surgery, (2) review current evidence directed at identifying risk factors and evaluating interventions to reduce readmissions across different medical and surgical specialties, and (3) identify key areas in patient care where targeted research or interventions may be implemented in vascular surgery.

Emotional stressors trigger cardiovascular events

To describe the relation between emotional stress and cardiovascular events, and review the literature on the cardiovascular effects of emotional stress, in order to describe the relation, the underlying pathophysiology, and potential therapeutic implications. Targeted PUBMED searches were conducted to supplement the authors' existing database on this topic. Cardiovascular events are a major cause of morbidity and mortality in the developed world. Cardiovascular events can be triggered by acute mental stress caused by events such as an earthquake, a televised high-drama soccer game, job strain or the death of a loved one. Acute mental stress increases sympathetic output, impairs endothelial function and creates a hypercoagulable state. These changes have the potential to rupture vulnerable plaque and precipitate intraluminal thrombosis, resulting in myocardial infarction or sudden death. Therapies targeting this pathway can potentially prevent acute mental stressors from initiating plaque rupture. Limited evidence suggests that appropriately timed administration of beta-blockers, statins and aspirin might reduce the incidence of triggered myocardial infarctions. Stress management and transcendental meditation warrant further study.

Topical Timolol for Small Hemangiomas of Infancy

Propranolol has become the treatment of choice of large and complicated infantile hemangiomas. There is a controversy concerning the safety of systemic propranolol. Here we show that topical use of the beta-blocker timolol can also inhibit the growth and promote regression of infantile hemangiomas. In this case series we treated 11 infantile hemangiomas in nine children including six preterm babies with the nonselective betablocker timolol. A timolol containing gel was manufactured from an ophthalmic formulation of timolol 0.5% eyedrops. This gel was applied using a standardized occlusive dressing (Finn-Chambers) containing approximately 0.25 mg of timolol. In all infants topical timolol was associated with growth arrest, a reduction in redness and thickness within the first 2 weeks. Seven hemangiomas showed almost complete resolution, and four became much paler and thinner. No data are available on the transdermal absorption of timolol. Even supposing complete absorption of timolol from the occlusive dressing, a maximum dose of 0.25 mg of timolol would result per day and hemangioma. Regression of infantile hemangiomas treated using 0.5% timolol gel in this case series occurred earlier than spontaneous regression which is generally not observed before the age of 9-12 months. The promising results need to be verified in prospective randomized trials on topical beta blocker administration for infantile hemangiomas which should address dose, duration, and mode of application.

Efficacy of beta-blockade after isolated blunt head injury: does race matter?

Several retrospective clinical studies and recent prospective animal models demonstrate improved outcomes with beta-blocker administration after isolated blunt head injury. However, no investigations to date have examined the influence of race on the potential therapeutic effectiveness of these medications. Our hypothesis was that mortality benefits associated with beta-blocker exposure after isolated blunt head injury varies based on ethnicity. The trauma registry and the surgical intensive care unit (ICU) databases of an academic Level I trauma center were used to identify all patients sustaining blunt head injury requiring ICU admission from July 1998 to December 2009. Patients sustaining major associated extracranial injuries (Abbreviated Injury Scale [AIS] score ≥ 3 in any body region) were excluded. Patient demographics, injury profile, Injury Severity Score, and beta-blocker exposure were abstracted. The primary outcome evaluated was in-hospital mortality stratified by ethnicity. During the 11-year study period, 3,750 patients were admitted to the Los Angeles County + University of Southern California Medical Center trauma ICU because of blunt trauma. Of these, 65% (n = 2,446) had an "isolated" head injury. When stratified by race, most patients were Hispanics (60%), followed by Whites (21%), Asians (11%), and African Americans (8%). After adjusting for confounding variables with multivariate regression, only those of Asian and Hispanic descent demonstrated significantly improved outcomes associated with beta-blocker administration. Our results indicate that beta-blockade after traumatic brain injury may not benefit all races equally. Further prospective research is necessary to assess this discrepancy in treatment benefit and explore other possible therapeutic interventions.

CT angiography using dual source 64-MSCT versus catheter angiography in assessment of coronary atherosclerotic disease

We compare the coronary CTA versus catheter angiography in the assessment of coronary atherosclerosis.The study included 51 patients who were referred for coronary catheter angiography after coronary CTA. The following patients were excluded: patients with irregular heart rates, patients with previous coronary bypass grafts and those with coronary stents. Patients with a resting heart rate above 75bpm and a medical contraindication for beta blockers administration are excluded. History of contrast allergy, renal impairment and severe chest conditions are exclusion criteria. The coronary angiographic CT studies were performed using a Somatom Definition “dual source” 64 CT scanner (Siemens, medical scientific Germany). The catheter coronary angiographic studies were performed via femoral arterial puncture. The standard 15-segment model of the coronary tree was employed. Segments were classified as being normal, atherosclerotic (with no significant stenosis), stenotic (>50% luminal narrowing), occlusive or non evaluable. The results of CT angiography are compared with the gold standard catheter angiography.Results: Overall sensitivity, specificity, PPV and NPV were 93%, 92%, 92% and 93%, respectively with an overall diagnostic accuracy of 93%. The sensitivity is 84% to detect stenoses 60–70% in, 85% sensitivity with 70–80% stenoses, 96% with 80–90% stenoses and 96% with stenoses more than 90%.

Topical beta-blocker treatment for migraine

Beta-blockers are a well-known prophylactic treatment for migraine; however, treatment by the ocular route has not been widely considered. This case illustrates the resolution of a visual field defect associated with migraine and improvement of symptoms possibly due to administration of a topical beta-blocker. This novel method of treatment especially when visual field defects are present may have a place in the management of migraine.

Antinociceptive effects of intrathecal landiolol injection in a rat formalin pain model.

Perioperative beta-blocker administration has recently been recommended for patients undergoing cardiac or other surgery due to the beneficial cardiovascular effects of these agents. In addition, some studies have reported that perioperatively administered beta-blockers also have analgesic effects. In this study, to investigate the antinociceptive effects and the analgesic profile of landiolol, we examined the effects of intrathecal landiolol administration on nociceptive pain behavior and c-fos mRNA expression (a neural marker of pain) in the spinal cord using a rat formalin model. We found that pain-related behavior was inhibited by intrathecal landiolol administration. Moreover, the increase in c-fos mRNA expression on the formalin-injected side was less pronounced in rats administered landiolol than in saline administered controls. Thus, intrathecal administration of landiolol exhibited antinociceptive effects. Further investigation of the antinociceptive mechanism of landiolol is required.

Abstract P196: Outcomes in Cocaine Chest Pain Patients Treated with β-Blockers

Introduction: Cocaine is the second most commonly used illicit drug in the US, and the most frequent illicit substance to precipitate an emergency room visit. Cocaine is associated with acute and chronic complications affecting the cardiovascular system. Although Beta blockers (BB) have been shown to improve outcomes in patients with ACS, current ACC/AHA guidelines call for avoidance of BB in patients presenting with chest pain and suspected MI with recent cocaine use due to concern for precipitating coronary vasoconstriction. Recently new data has emerged on beta blockade following cocaine intoxication, demonstrating improved cardiovascular hemodynamics and patient outcomes. In this study we looked at clinical outcomes of patients with cocaine chest pain that received BB therapy. Methods: All patients presenting to the Thomas Jefferson University Hospital Emergency Department (ED) with a chief complaint of chest pain from April 2007 to September 2008 were included (n=5432). Retrospective chart review was conducted on 37 individuals with cocaine positive urine drug screen that received BB. Data was collected on gender, previous history of MI, outpatient BB therapy, and cardiovascular outcomes (hypertensive emergency, MI, stroke, cardiac arrest or death). Results: Of the 37 patients that were cocaine positive and received BB therapy, 33 were male, 18 had a prior MI, and 24 were on outpatient BB therapy. There were no reports of hypertensive emergency, stroke, cardiac arrest or death following BB therapy. Four patients were diagnosed with MI, but in all cases the troponin assay was positive prior to BB administration. When compared with cocaine positive patients who did not receive a BB, there was no significant increase in negative cardiovascular outcomes following BB therapy. Conclusions: We found no increase in adverse events or negative cardiovascular outcomes following Beta blocker therapy in patients with cocaine associated chest pain. This study adds to the body of evidence showing BB may not be harmful in patients with cocaine associated chest pain and myocardial ischemia. Given the strong evidence supporting BB use in ACS, further study is warranted to investigate whether BB therapy may be beneficial in certain cocaine chest pain patients.

Ivabradine Versus Metoprolol for Heart Rate Reduction Before Coronary Computed Tomography Angiography

Several studies have demonstrated the correlation of heart rate (HR) and image quality in coronary computed tomography angiography. Beta-blocker administration is critical because of its negative inotropic effect. Ivabradine is a selective HR-lowering agent that exclusively inhibits the I(f) current in sinoatrial node cells without having any effect on cardiac contractility or atrioventricular conduction. A total of 120 patients were randomized to oral premedication with ivabradine 15 mg or metoprolol 50 mg. HR and blood pressure (BP) were measured before the administration of premedication and immediately before coronary computed tomographic angiography. The mean time between premedication administration and follow-up was 108 ± 21.5 minutes for ivabradine and 110 ± 22.2 minutes for metoprolol (p = NS). When comparing groups, there were no significant differences in reduction of HR (-11.83 ± 8.6 vs -13.20 ± 7.8 beats/min, p = NS) and diastolic BP (-5.05 ± 14.2 mm Hg vs -4.08 ± 10.8 mm Hg, p = NS), whereas the decrease of systolic BP was significantly lower in patients who received ivabradine compared to those in the metoprolol group (-3.95 ± 13.6 vs -13.65 ± 17.3 mm Hg, p <0.001). In the subgroup of patients who were receiving long-term β-blocker therapy, significantly stronger HR reduction was achieved with ivabradine (-13.19 ± 5.4 vs -10.04 ± 6.0 beats/min, p <0.05), while the decrease in systolic BP was less (-2.00 ± 13.6 vs -15.04 ± 20.8 mm Hg, p <0.05) compared to metoprolol. In conclusion, ivabradine decreases HR before coronary computed tomographic angiography sufficiently, with significantly less depression of systolic BP compared to metoprolol.

Team training can improve operating room performance

This study was conducted to determine if team training using a federally sponsored team training program improves operating room (OR) performance and culture. The TeamSTEPPS program, a team training program designed and tested for health care applications, was provided to the OR staff. The training occurred over 2 months to all members of the OR team, including scrub technicians, nurses, certified registered nurse anesthetists, anesthesiologists, surgeons, and all anesthesiology and surgical resident staff. After 9 months, there was a significant improvement in the OR staff team work (score 53.2 to 62.7; P < .05) and OR communications (score 47. 5 to 62.7; P < .05). There was significant improvement in OR first case starts (69% to 81%), Surgical Quality Improvement Program measures (antibiotic administration, 78% to 97% [P < .05]; venous thromboembolism administration, 74% to 91% [P < .05]; and beta blocker administration, 19.7% to 100%; P < .05) and patient satisfaction (willingness to recommend, 77% to 89.3% [P < .05]). NSQIP measured overall surgical morbidity and mortality, which were both significantly improved (mortality, 2.7% to 1% [P < .05]; morbidity, 20.2% to 11.0% [P < .05]), indicating a significant change in the overall OR culture. A year later, the data showed that factors linked to regulatory requirements, such as Surgical Quality Improvement Program measures linked to the time out remained improved while first case on time starts decreased (81% to 69%; P < .05), patient willingness to recommend decreased (89.3% to 80.8%; P < .05), surgical mortality increased (1% to 1.5%; P < .05), and surgical morbidity increased (11% to 13%; P < .05) reflecting a degree of culture deterioration which has persisted. These data confirm that team training improves OR performance, but continued team training is required to provide sustained improved OR culture.

Minimizing cardiac risk in perioperative practice – interdisciplinary pharmacological approaches

In an aging population, major surgery is often performed in patients with complex co-morbidities. These patients present new risk constellations so that cardiac and respiratory complications mainly contribute to perioperative morbidity. We composed a narrative review on pharmacological approaches to cardiovascular protection in the perioperative period including effects of central neuraxial blocks and hypothermia on cardiovascular outcome. The single chapters are structured as follows: pathophysiology-early studies-recent evidence-recommendations. In coping with this challenge, innovative concepts like fast track surgery and pharmacological treatment are being utilized with increasing frequency including perioperative cardioprotection, novel strategies of anticoagulation or antiplatelet therapy, and protocols for postoperative pain therapy. All the concepts described require an interdisciplinary approach in collaboration between operative physicians and physicians working in non-surgical disciplines like internal medicine, cardiology, and clinical pharmacology. The perioperative continuation of a pre-existing therapy with beta-blockers and other potentially cardioprotective agents like α(2)-agonists and statines is recommended. In the management of patients presenting for major surgery stratification of the perioperative risk is essential which considers both, invasiveness of the surgical procedure and conditions of the patient. Otherwise, side-effects might outweigh benefits of a potentially effective therapy as recently shown for the perioperative administration of beta-blockers that should be restricted to high-risk patients.

Reducing elevated heart rate in patients with multiple organ dysfunction syndrome by the I f (funny channel current) inhibitor ivabradine

Heart rate (HR) is of relevant prognostic value not only in the general population and patients with cardiovascular disease, but also in critically ill patients with multiple organ dysfunction syndrome (MODS). An elevated HR in MODS patients is associated with a worse prognosis. Beta-blocker (BB) administration has been shown to reduce mortality in MODS. In most cases, negative inotropic effects prevent administration of BBs in MODS patients. In this trial we investigate, whether the "funny current" (I (f)) channel inhibitor ivabradine is able and apt to reduce pathologically elevated HR in MODS patients. We hypothesize that critically ill patients could derive particular benefit from the specific HR-lowering agent ivabradine. MODI (f)Y is a prospective, single centre, open label, randomized, controlled two arms, phase II-trial to evaluate the potential of ivabradine to reduce an elevated HR in MODS patients. The primary end point is the proportion of patients with a reduction of HR by at least 10 beats per minute (bpm) within 4days. This trial will randomize 70 patients (men and women, aged ≥18years) with newly diagnosed MODS, with an elevated HR (sinus rhythm with HR ≥90bpm) and contraindications to BB therapy. Treatment period will last for 4days. All patients will be followed for 6months. The first patient was randomized on May 21, 2010. The MODI (f)Y trial is the first application of ivabradine as a pure heart rate reducing agent in MODS patients.

Transmural myocardial ischaemia complicating recovery after dobutamine-atropine stress echocardiography in patients with non-significant coronary artery disease: insights from invasive assessment of coronary physiology

In the proposed selection of cases, traditional imaging is integrated with contemporary diagnostic tools available in the cath-lab to navigate the potential mechanisms underlying a very rare complication occurring in the recovery phase of dobutamine-atropine stress echocardiography. The data, collected in a time frame of nearly 15 years, provide interesting elements to possibly evolve from speculative considerations to plausible confirmation of the candidate pathophysiological mechanism mediating the occurrence of transmural myocardial ischaemia after beta-blockers administration.

Invited commentary

In the past decade, business interests and government policy makers undertook to “refine” the delivery of health care by proposing guidelines that would codify aspects of patient care delivery. The proposed impetus was to improve quality and decrease costs for treating conditions like congestive heart failure, surgical infections, and vascular surgery-related myocardial infarction. The assumption implicit to these guidelines was that physicians and the health care systems they participate in were not interested in or able to improve health care with data-driven strategies. The club of reimbursement was used to drive these quality initiatives, implying that physician concern for the welfare of their patients was not adequate to achieve good results. The excellent article by Goodney et al1Goodney P.P. Eldrup-Jorgensen J. Nolan B.W. Bertges D.J. Likosky D.S. Cronenwett J.L. A regional quality improvement effort to increase beta blocker administration before vascular surgery.J Vasc Surg. 2011; 53: 1316-1328Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar highlights two very important points to remember and publicize as we go forward in the debate on health care reform. The first is that intelligent, well-trained physicians are better able to care for their patients than are committees who believe they have a “special ability” to understand “evidence-based medicine.” Physicians learn early in their training to read the literature with a critical eye and to determine how best to apply new science to their patients. Mandated guidelines are only as good as the data they are based on. They are not able to accommodate specific patient needs, nor are they nimble enough to adapt to new data the way individual physicians do daily. The guidelines urging beta-blockers for vascular patients are a great example of how rushing to “standardize” care pre-empted the wisdom of facts gained through multiple subsequent, well-designed studies and analyses. Medicine may seem to change glacially at times, but I believe this reflects a careful and ongoing critical analysis by physicians of “new science” rather than ignorance or indifference to patient welfare. We practice evidence-based medicine daily. Unfortunately, the evidence is often not as straightforward as the media and pundits would purport. The second important point in this report is that physicians, convinced that a new therapy or approach is in their patients' best interest, will adopt it. The physicians in this research consortium quickly and effectively instituted beta-blocker use, expecting to improve their patients' care. This occurred without financial incentives. I commend the authors for their scientific contribution on the role of beta-blockers in vascular surgery. I also thank them for affirming what I believe about our profession. As a group, physicians, with our speciality societies, will do what is best for our patients. We do not need “Big Brother” herding us to achieve this. We are our patients' best advocates and we must resist the efforts of politicians, lawyers, business interests, and insurance vendors to convince society otherwise. A regional quality improvement effort to increase beta blocker administration before vascular surgeryJournal of Vascular SurgeryVol. 53Issue 5PreviewTo determine if a regional quality improvement effort can increase beta-blocker utilization prior to vascular surgery and decrease the incidence of postoperative myocardial infarction (POMI). Full-Text PDF Open Archive

The effect of metoprolol alone and combined metoprolol–felodipin on the digital microcirculation of patients with primary Raynaud's syndrome

Objectives Calcium channel inhibitors have beneficial impact on microcirculation, but beta-blocker effect is controversial. Clinicians still do not agree on beta-blocker combination with other treatments in the management of impaired microcirculation. The aim of the present study was to describe the effects of beta-blocker metoprolol monotherapy and combined with calcium channel inhibitor felodipin on digital microcirculation in primary Raynaud's syndrome. Methods We enrolled in this study 46 patients suffering from both hypertension and primary Raynaud's syndrome. Fifteen patients were treated with beta-blocker monotherapy (metoprolol), 13 received combined beta-blocker and calcium channel blocker therapy (felodipin and metoprolol), while 18 patients without any medications served as controls. Measurement of digital microcirculation was carried out with laser Doppler scanner. Results and conclusions Our investigation concludes that the concurrent administration of beta-blockers with calcium channel inhibitors positively reduces symptoms in patients suffering from Raynaud's syndrome.

Endoscopic variceal band ligation compared with propranolol for prophylaxis of first variceal bleeding

Administration of nonselective beta-blockers in prophylaxis of first variceal bleeding is not suitable for all patients. Thus, we evaluated endoscopic variceal band ligation (EVBL) in primary prevention of bleeding in patients with cirrhosis and large esophageal varices. A total of 73 consecutive patients with liver cirrhosis and large esophageal varices without a history of gastrointestinal bleeding were randomized to receive either EVBL or propranolol and were followed for up to 18 months. Forty patients underwent EVBL and 33 patients received propranolol. Variceal bleeding occurred in 2 patients in the EVBL (5%) and in 2 patients in the propranolol group (6%, NS). The 18 month actuarial risk for first variceal bleed was 5% in the EVBL (95% CI, 0-12%) and 20% in the propranolol group (95% CI, 0-49%, NS). The actuarial probability of death at 18 months of follow-up was 5% (95% CI, 0-11%) in the EVBL group and 7% (95% CI, 0-17%, NS) in the propranolol arm. In conclusion, EVBL was an effective and safe alternative to propranolol in primary prophylaxis of bleeding in patients with large esophageal varices.

Changes Over Six Years in Administration of Aspirin and Beta Blockers on Arrival and Timely Reperfusion and in In-Hospital and 30-Day Postadmission Mortality in Patients With Acute Myocardial Infarction

There is conflicting evidence regarding the impact of improving quality-of-care measures on patient outcomes. From July 2002 through June 2008, compliance with 3 in-hospital acute myocardial infarction quality-of-care measures (administration of aspirin and β blockers on arrival, timely reperfusion) and mortality were assessed in consecutive patients eligible for ≥1 of the measures at 8 hospitals (n = 6,826). Adjusted odds ratios for in-hospital and 30-day postadmission mortality and rate ratios for compliance with the 3 quality-of-care measures were calculated using marginal structural models to assess differences over time. Compliance with the 3 in-hospital quality-of-care measures improved significantly over the 6-year period. Adjusted odds ratios (95% confidence intervals) revealed significant decreases in in-hospital mortality in cohorts eligible for aspirin at arrival (year 6 vs baseline 0.37, 0.22 to 0.65), β blockers at arrival (year 6 vs baseline 0.24, 0.11 to 0.52), and an "all-eligible" measure comprising aspirin at arrival, β blockers at arrival, and timely reperfusion (year 6 vs baseline 0.41, 0.24 to 0.69). Significant decreases in 30-day postadmission mortality followed the same pattern (aspirin at arrival 0.53, 0.35 to 0.80; β blockers at arrival 0.43, 0.26 to 0.73; all-eligible measure 0.54, 0.36 to 0.81). In conclusion, over the 6-year study period, the health care system's compliance with the 3 in-hospital quality-of-care measures and 30-day mortality improved significantly.

Evening Administration of Long-Acting Beta-Blockers for Primary Prophylaxis in Cirrhosis: An Effective Strategy

1Advanced Liver Diseases Study Group, Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA Correspondence: Jayant A. Talwalkar, MD, MPH, Advanced Liver Diseases Study Group, Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905, USA. E-mail: [email protected] This letter underwent AJG editorial review.