BB Use Research Articles

Effect of beta-blocker therapy on heart rate response in patients with hypertension and newly diagnosed untreated obstructive sleep apnea syndrome

BackgroundBeta1-receptor antagonists (BBs) are commonly administered in the treatment of cardiovascular disease (CVD). The reported benefits of BB use in CVD patients with concomitant obstructive sleep apnea (OSA) may be limited by their impact on apnea-induced bradycardias. Therefore the aim of the study was to test the influence of BBs on periapneic heart rate (HR) fluctuations in hypertensive patients with newly-detected and untreated OSA. MethodsWe studied 88 hypertensive patients (56 on BBs and 32 BB naive) with newly-diagnosed moderate-to-severe OSA who were free of major pulmonary comorbidities and did not require antiarrhythmic therapy. ECGs recorded during sleep were investigated for heart rate (HR) responses to apneas allowing to compare extreme HR accelerations and decelerations between the groups. ResultsAverage sleep-time HR was comparable in BB-naive (BB−) and BB-treated (BB+) patients. Direct comparisons showed that HR decelerations were also similar in the two subgroups (53.8±9.6 vs. 54.4±7.8bpm; P=0.78, for BB− and BB+, respectively) however, BBs blunted the OSA-induced HR accelerations (82.3±12.2 vs. 74.3±10.0; P=0.003). After adjusting for baseline HR and magnitude of desaturations, HR decelerations were more evident in BB-naive group whereas tachycardic responses remained blunted in the BB+ group. The incidence of ectopies and conduction abnormalities were comparable across two groups. ConclusionsBeta-blockers do not potentiate apnea-induced HR decelerations, attenuate apnea-induced increases in heart rate and do not influence incidence of ectopies and conduction abnormalities in patients with hypertension and moderate-to-severe, untreated OSA.

Association Between Glaucoma, Glaucoma Therapies, and Erectile Dysfunction

To examine the association between (1) glaucoma and erectile dysfunction (ED) and (2) topical β-blocker (BB) use and ED. A comprehensive, province-wide database of physician visits and diagnoses and prescription drug dispensing was used to identify cases of ED (1380) and find corresponding controls (13,800). A conditional logistic regression model was used to estimate rate ratios for 2 main exposures: (1) diagnosis of glaucoma and (2) use of a prescription of a topical BB before the index date. A variety of risk factors were adjusted for. Cases were more likely to have coronary artery disease, chronic obstructive pulmonary disease, and diabetes. A crude rate ratio of the current diagnosis of ED in a population with at least 2 separate diagnoses of glaucoma was 1.34 and when adjusted for a number of variables (including oral BB use), this ratio was 1.37 [95% confidence interval (CI), 1.06-1.76]. Use of topical BB in the 30 days before the diagnosis of ED did not have a significant association with a diagnosis of ED, with crude and adjusted rate ratios of 1.05 and 1.10, respectively (95% CI, 0.61-1.99). Topical ocular prostaglandin use was also not associated with ED, with crude and adjusted rate ratios of 0.96 and 0.93, respectively (95% CI, 0.57-1.53). Our results confirmed an association between ED and glaucoma that cannot be attributed to topical BB use. Given that most cardiovascular and metabolic risk factors were adjusted for, further research in this area will be necessary to elucidate the nature of this association and potential causation.

Do Preoperative β-blockers Improve Postoperative Outcomes in Patients Undergoing Cardiac Surgery? Challenging Societal Guidelines

Preoperative β-blockers (BBs) are widely administered to reduce morbidity and mortality among surgical patients. In fact, the Society of Thoracic Surgeons uses the administration of preoperative BBs as a quality metric. Recent reports, however, have questioned the benefit and safety of preoperative BB administration. The aim of our study was to investigate whether preoperative BBs lead to improved surgical outcomes in patients undergoing cardiac surgery. A review of our prospectively maintained institutional database was done to identify adults undergoing cardiac operations at our institution from 2008 to 2013. Survival to discharge was the primary outcome with several additional secondary measures of morbidity included. A total of 2120 patients were included in the analysis and a multivariate logistic regression model was developed to adjust for differences between patient groups. After adjustment, BB administration was associated with lower odds of both prolonged ventilation (odds ratio [OR], 0.73; P = 0.032) and prolonged length of stay (OR, 0.79; P = 0.044). BB use was not associated with significant differences in other outcomes such as mortality or postoperative atrial fibrillation. Our study found that preoperative BBs may not be associated with sufficiently improved outcomes to justify their use as a quality metric in this population. Thus, prospective studies are warranted.

Changes in Hospital Mortality of Emergency Hospitalization Severe Heart Failure Patients Using DPC Data

Heart Failure (HF) accounts for a large number of hospitalization and contributes significantly to mortality. 348 cases of HF patients admitted to our the hospital from April 2009 to March 2013. We examined the effect factors and changes in hospital mortality using the DPC analysis software EVE. (1) In-hospital mortality rate was improved from 14.4% to 9.3%. (2) Changes in the treatment of heart failure drug usage: <Injection drugs> cardiotonic/diuretic decreased and carperitide increased. <Oral medicine> ACEI/ARB and beta-blockers increased slightly. Oral inotropic agents decreased. The prognosis of severe emergency inpatient improved year by year, the selection of an appropriate drug for HF was one of the causes.Tabled 1Year2010 (n=82)2013 (n=54)Age (years)83.578.3In-hospital mortality (%)18.39.3infusion DOB/DOA use (%)5617 Furosemide use (%)9472 Carperitide use (%)3741Medications ACEI/ARB use (%)5667 BB use (%)4146 Inotropic agents use (%)177 Open table in a new tab

Preoperative CYP2D6 metabolism-dependent β-blocker use and mortality after coronary artery bypass grafting surgery

Recently, the role of β-blockers (BBs) in reducing perioperative mortality has been challenged. The conflicting results might have resulted from the extent of BB metabolism by the cytochrome P-450 (CYP2D6) isoenzyme. The purpose of the present study was to assess the association between the preoperative use of BBsdependent on metabolism of the CYP2D6 isoenzyme with operative mortality after coronary artery bypass grafting surgery. We performed a retrospective study of 5248 patients who had undergone coronary bypass grafting surgery from January 1, 2001 to November 30, 2009 at Duke University Medical Center. The cohorts were defined by the preoperative use of BBs and BB type (non-CYP2D6_BBs, CYP2D6_BBs, or no BBs). Operative mortality was analyzed using inverse probability-weighted estimators with propensity score adjustment. Of the 5248 patients, 14% received non-CYP2D6_BBs, 43%, CYP2D6_BBs, and 43%, no BBs. The incidence of operative mortality was 0.8%, 2.1%, and 3.7% in the non-CYP2D6_BB, CYP2D6_BB, and no BB groups, respectively. Multivariable inverse probability-weighted-adjusted analyses showed that non-CYP2D6_BBs were associated with a lower incidence of operative mortality (odds ratio, 0.33; 95% confidence interval, 0.13-0.83; P=.02) compared with no BB use and a trend toward lower operative mortality (odds ratio, 0.44; 95% confidence interval, 0.16-1.07; P=.06) compared with CYP2D6_BBs. No significant decrease occurred in the risk of operative mortality between the CYP2D6_BB and no BB groups (odds ratio, 0.85;95% confidence interval, 0.54-1.34; P=.48). Among these patients, preoperative non-CYP2D6_BB use, but not CYP2D6_BB use, was associated with a decreased risk of operative mortality.

Impact of Pre-Procedural Beta Blockade on Inpatient Mortality in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction

Early use of β blockers (BBs) in acute myocardial infarction remains controversial, with some studies demonstrating benefit and others harm. The aim of this study was to assess the association between pre-percutaneous coronary intervention (PCI) BB use and in-hospital outcomes in patients who underwent primary PCI for ST-segment elevation myocardial infarction between 2007 and 2009 at institutions participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC-2). Inverse propensity score weighting was used to account for the nonrandomized use of pre-PCI BBs. The cohort comprised 7,667 patients, with 4,769 (62%) receiving pre-PCI BBs. These patients were older, with higher rates of diabetes mellitus, hypertension, and previous myocardial infarction, PCI, or coronary artery bypass grafting. In adjusted models, pre-PCI BB use was associated with lower rates of intraprocedural ventricular tachycardia or ventricular fibrillation (odds ratio [OR] 0.58, p <0.01) and lower in-hospital mortality (OR 0.65, p = 0.022), with increases in rates of emergent coronary artery bypass grafting (OR 1.56, p <0.01) and repeat PCI (OR 1.93, p <0.01). There were no significant increases in rates of cardiogenic shock and congestive heart failure. In conclusion, pre-PCI BB use in this population was associated with decreased arrhythmia and mortality, without increasing rates of cardiogenic shock and heart failure but with higher rates of repeat PCI and emergent coronary artery bypass grafting, suggesting that there may yet remain a role for early BB use in pre-PCI patients with ST-segment elevation myocardial infarctions.

Gender and prior beta blockers use in patients presenting with acute coronary syndrome in Arab Middle Eastern population

Introduction To evaluate the impact of prior beta blockers (PBB) use in women and men presenting with acute coronary syndrome (ACS). Methods Data were collected from a prospective multicenter study of the second Gulf Registry of Acute Coronary Events in six Middle Eastern countries from October 2008 to June 2009. Patients were categorized into two groups according to their PBB use. Data were analyzed and compared in women and men. All-cause mortality rates were reported at 30 days and 1 year. Results Among 7930 ACS patients; 2300 (29%) patients were on PBB. Patient with PBB were 622 (37%) women and 1688 (27%) men. Patients with no PBB use were more likely smokers and presented mainly with STEMI. Absence of PBB use was associated with higher GRACE risk score in comparison to those with PBB use. BB use increased from 37% to 89% on arrival in women and from 27% to 91% in men. Women with no PBB use had higher hospital mortality in comparison to their counterparts with PBB use (8% vs 5%, P = 0.03). Men with no PBB use had higher incidence of ventricular tachyarrhythmias in comparison to their counterparts with PBB use (3.5% vs 1.9%, P = 0.001). PBB use was independent predictor for 1-month mortality in men (OR 0.61; 95% CI 0.44–0.85). Conclusions There is substantial increase in the use of BB in the current study, but still lower than the international standard. Although patients with PBB use had worse baseline profiles, they had lower incidence of ventricular arrhythmias and mortality.

Beta Blocker Use After Acute Myocardial Infarction in the Patient with Normal Systolic Function: When is it “Ok” to Discontinue?

Beta-Blockers [BB] have been used extensively in the last 40 years after acute myocardial infarction [AMI] as part of therapy and in secondary prevention. The evidence for “routine” therapy with beta-blocker use post AMI rests largely on results of trials conducted over 25 years ago. However, there remains no clear recommendation regarding the appropriate duration of treatment with BBs in post AMI patients with normal left ventricular ejection fraction [LVEF] who are not experiencing angina, or who require BB for hypertension or dysrhythmia. Based on the latest ACC/AHA guidelines, BBs are recommended for early use in the setting of AMI, except in patients who are at low risk and then indefinitely as secondary prevention after AMI. This recommendation was downgraded to class IIa in low risk patients and the updated 2007 ACC/AHA guidelines suggest that the rationale for BB for secondary prevention is from limited data derived from extrapolations of chronic angina and heart failure trials. In this review, we examine the key trials that have shaped the current guidelines and recommendations. In addition, we attempt to answer the question of the duration of BB use in patients with preserved LVEF after acute MI, as well as which subgroups of patients benefits most from post AMI use of beta blockers.

P48 Should chronic obstructive pulmonary disease be a contra-indication to β blocker prescription in patients with concomitant heart failure?

IntroductionBeta blockers (BB) are now well established in the treatment of heart failure (HF) and other cardiovascular disorders. There is much debate in the literature as to their safety in...

Treatment and outcomes in patients with myocardial infarction treated with acute β-blocker therapy: Results from the American College of Cardiology’s NCDR®

Although β-blockers (BBs) reduce long-term mortality in patients after myocardial infarction (MI), data regarding acute usage are conflicting. We examined acute (≤24 hours) BB use in 34,661 patients with ST-elevation MI (STEMI) and non-ST-segment MI (NSTEMI) included in the NCDR(®) ACTION Registry(®)-GWTG™ (291 US hospitals) between January 2007 and June 2008. Patients with contraindications or did not receive BBs or with missing data were excluded. We analyzed the use and impact of BB stratified by variables associated with increased risk for shock specified in the recent guidelines: age >70 years, symptoms >12 hours (STEMI patients), systolic blood pressure <120 mm Hg, and heart rate >110 beat/min on presentation. Among patients without contraindications, at least 1 high-risk variable was found in 45% of STEMI and 63% of NSTEMI patients. In-hospital complications including cardiogenic shock, mortality, and the composite outcome of shock or mortality were significantly increased with more shock risk factors in both STEMI and NSTEMI patients. Very early use in the emergency department was associated with a significantly increased risk of shock for both STEMI and NSTEMI patients compared to patients treated later but within 24 hours. Risk factors for shock are common in STEMI and NSTEMI patients treated with early BBs. Increasing numbers of risk factors were associated with increased risk for shock or death in patients treated with BBs. These results are consistent with current recommendations for avoiding early BB treatment for patients with acute MI.

Has the ClOpidogrel and Metoprolol in Myocardial Infarction Trial (COMMIT) of early β-blocker use in acute coronary syndromes impacted on clinical practice in Canada? Insights from the Global Registry of Acute Coronary Events (GRACE)

The COMMIT/CCS-2 trial, published in 2005, demonstrated no net benefit of early β-blocker (BB) therapy in acute coronary syndromes (ACS). We sought to assess the short-term impact of this landmark trial by comparing the use of early BB therapy in patients with a broad spectrum of ACS before and after 2005. Using data from the Global Registry of Acute Coronary Events and Canadian Registry of Acute Coronary Events, we compared the rates of BB use within the first 24 hours of presentation in the periods 1999 to 2005 and 2006 to 2008, after stratifying patients by the type of ACS (ST-segment elevation myocardial infarction [STEMI] and non-ST-segment elevation ACS [NSTEACS]) and clinical presentation. Of the 14,231 patients with ACS, 77.7% received BB therapy within 24 hours of presentation (78.5% and 77.4% in the STEMI and NSTEACS groups, respectively). The early use of BB declined in the STEMI group (80.3% to 76.7%, P = .005) but increased in the NSTEACS group (75.4% to 78.9%, P < .001) after 2005. Long-term BB use, higher systolic blood pressure, and higher heart rate were independent predictors of early BB use. Conversely, patients who were female, older, Killip class >1, and had cardiac arrest at presentation were less likely to receive early BB. Multivariable analysis showed a trend toward lower use of BB among patients with STEMI (adjusted odds ratio 0.76, 95% CI 0.57-1.00, P = .055) and a trend toward more frequent BB use among patients with NSTEACS (adjusted odds ratio 1.22, 95% CI 0.96-1.55, P = .11) after 2005. The temporal trends in the early use of BB differed between patients with STEMI and patients with NSTEACS (P for interaction with period <.001). Most patients with STEMI or NSTEACS were treated with early BB therapy. In accordance with the COMMMIT/CCS-2 trial, patients with lower systolic blood pressure and higher Killip class in the "real world" less frequently received early BB therapy. Since the publication of COMMIT/CCS-2, there has been no significant change in the use of BB in patients with STEMI or NSTEACS after controlling for their clinical characteristics.

Abstract 4881: Interaction of Genetic and Pharmacologic β -adrenergic Signaling Inhibitors Determines Long-term Mortality after Acute Coronary Ischemia

Introduction: While chronic β-blocker (BB) therapy after myocardial infarction (MI) reduces the long-term risk of death, recent studies suggest that BB within 24h after MI is associated with increased death from cardiogenic shock. We have described a naturally-occurring G-protein Receptor Kinase ( GRK )5 L41 polymorphism that mimics BB effects in experimental models and human heart failure raising the possibility that pre-existing “genetic β-blockade” might also affect outcomes after MI. Methods: 3,244 patients hospitalized with acute coronary ischemic syndromes (ACS; 2,943 MI; 301 unstable angina) were followed for an average of 2.7 years. Primary endpoint was time to death. A sub-cohort (n=973) was followed for time to rehospitalization. Independent variables were antecedent BB therapy (a-BB), discharge BB therapy (d-BB), and GRK5 Q41L genotype. Differences were assessed with Kaplan Meier curves, log-rank tests, and Cox proportional hazards modeling (HR). Results: Complete data were available for 2,732 subjects (24% African American [AA], 33% female, 32% a-BB, 87% d-BB). Overall mortality rate was 12%, and rehospitalization occurred in 41%. AA had increased mortality risk (HR=1.32, CI= 1.017–1.71, p=0.037). a-BB significantly increased mortality in both AA (HR=1.69, CI=1.006–2.84, p=0.047) and Caucasians (HR=1.98, CI=1.523–2.57, p=0.00000033). GRK5 L41 is more common in AA. GRK5 L41 carrier status did not significantly affect mortality in AA or Caucasian non-BB subjects, but protected against death in AA with a-BB (HR=0.456, CI= 0.256 – 0.812, p=0.0076; p value for gene-drug interaction=0.041). In the rehospitalization sub-study, GRK5 L41 protected AA from rehospitalization, independent of BB use (HR=0.605, CI=0.388 – 0.943, p=0.026). d-BB status was not associated with mortality or rehospitalization after discharge. Conclusions: Antecedent, but not discharge, treatment with BB is associated with adverse long-term outcomes in ACS patients requiring hospitalization. In contrast, AA patients carrying the GRK5 L41 polymorphism are protected against death and rehospitalization. “Genetic β-blockade” may have advantages over, and can oppose some untoward consequences of, pharmacological β-receptor antagonism in ACS patients.

Chronic obstructive pulmonary disease in heart failure. Prevalence, therapeutic and prognostic implications

Patients with heart failure (HF) frequently have comorbidities. Frequency, prognostic, and therapeutic implications of chronic obstructive pulmonary disease (COPD) in HF are largely unknown. We aimed to assess the prevalence and prognostic implications of COPD in a sample of stable patients with HF and to determine the frequency of beta-blocker (bB) use and rate of withdrawal according to COPD coexistence. We conducted a retrospective cohort study including 186 patients followed in an outpatient HF clinic. All patients had left ventricular systolic dysfunction and a spirometry result. Patients were classified according to the GOLD guidelines. Treatment was instituted at the discretion of the attending physicians. Prognosis was compared between groups using Cox proportional hazards regression. The primary end point was death or all-cause hospitalization. The prevalence of COPD was 39.2% (73/186). No difference was detected between the COPD and non-COPD groups in the rate of bB use (86.3% vs 87.6%, P = .97) and withdrawal (11.1% and 8.1%, P = .71). Mean follow-up was 14.2 +/- 8.8 months. The primary end point occurred in 71 (38.2%) patients--32 in the COPD group and 39 in the remaining (43.8% and 34.5%, respectively; hazard ratio 1.40, 95% CI 0.88-2.24). Severe COPD (GOLD stages III and IV) was associated with an adverse outcome (hazard ratio 2.10, 95% CI 1.05-4.22). We observed a high COPD prevalence in stable patients with HF. Severe COPD predicted worse prognosis. Rates of bB use were high and rates of bB withdrawal were low; both were independent of COPD.

Does Tricuspid Regurgitation Contribute to Renal Dysfunction in Patients With Heart Failure?

Results: There was no morbidity associated with exercise testing. Baseline estimated metabolic equivalents (METs) were 6.1± 3.0 (mean±S.D.) for patients with severe LVD and 7.3± 2.3 for patients with moderate LVD (p< 0.001). Pressure-rate product (PRP;×100) was 147± 44 for severe LVD and 163± 42 for moderate LVD (p< 0.05). During the program, 18 patients were referred to other rehabilitation units. By the end of the 6-week exercisetraining program (ET), 157 patients (62%) completed cardiac rehabilitation out of the remaining 252 eligible patients. The benefits of completed ET were examined by repeat exercise testing. For the 57 patients with severe LVD, METs improved with ET from 6.5± 2.4 to 8.9± 2.9 (p< 0.001), although PRP was unchanged (155± 49 versus 166± 49). For the 100 patients with moderate LVD, METs improved from 7.3± 2.1 to 10.3± 2.6 (p< 0.001), and PRP increased at peak exercise from 156± 47 to 171± 49 (p< 0.01). Conclusions: Stable patients with moderate or severe LVD can achieve reasonable workloads at exercise testing, with a significant improvement in workloads (average 2–3 METs) in patients completing 6 weeks of ET. This in turn would suggest a potential for at least a 26% reduction in mortality based on current data. doi:10.1016/j.hlc.2008.05.336 336 111± 20). For pts with moderate LVD, resting HR did not change during CR (73± 13 vs. 70± 12), and resting systolic BP rose a little from 113± 19 to 117± 21 (p< 0.05). Conclusions: In this cohort of stable pts with moderate to severe LVD, there was a high level of BB and ACE use, especially in pts with severe LVD. The levels observed in this study are congruent with or better than recently presented Australian studies [Driscoll et. al., Bennett et al. Asia-Pacific Congress of Heart Failure; 2008]. Resting HR averaged≥70, implying incomplete beta blockade inmany pts. doi:10.1016/j.hlc.2008.05.337

Are Patient Age and Gender Associated with Delivery of Recommended HF Therapies?

Introduction: The association of patient age and/or gender with the delivery of indicated HF therapies in the outpatient setting has not been well studied. Methods: IMPROVE HF is a prospective cohort study designed to characterize the current management of outpatients with chronic systolic HF in a registry and evaluate the effect of practice-specific performance-improvement interventions on the quality of care. Baseline performance data in eligible patients was collected by trained chart abstractors. Data were stratified and analyzed as male/female and by age tertiles. Comparisons were analyzed using Pearson chi-square. Results: 131 cardiology practices are enrolled with data abstracted for 12331 patients. Of these, 8770 (71.1%) of patients are male. Median patient age among female patients is 72.0 years and 70.0 among males. Median LVEF was 25.0%. ACEI, ARB, BB and CRT use were not significantly different between male and female patients, but ICD, anticoagulation for A-fib, and HF education were reduced among eligible female patients. Older patients were significantly less likely to receive most guideline-indicated HF therapies (Table). Conclusions: Both patient age and gender independently significantly influenced delivery of some but not other HF therapies in the outpatient arena. Practice-specific performance-improvement initiatives may close the age and gender treatment gap and improve overall quality of HF care.Tabled 1Influence of Age and Gender on HF Quality of CareMaleFemale≤ 64 years64 < Age ≤ 76> 76 yearsPerformance Measure(n = 8770)(n = 3551)P Value(n = 4217)(n = 4115)(n = 3862)P ValueACEI/ARB %79.578.30.16784.380.272.3< 0.001ß Blocker %84.785.40.38189.285.080.4< 0.001∗Aldo Antag %33.937.20.19145.231.126.5< 0.001Anticoag for A-fib%70.664.80.00471.270.067.40.204∗CRT-P/CRT-D %38.638.10.89338.941.835.10.160∗ICD/CRT-D %53.043.1< 0.00151.555.742.6< 0.001HF Education %61.959.70.02665.260.258.0< 0.001∗Inclusion requires documentation of NYHA class/functional status. The number of eligible patients for these measures may be substantially larger and conformity rates lower as a result of incomplete documentation of NYHA class. Open table in a new tab ∗Inclusion requires documentation of NYHA class/functional status. The number of eligible patients for these measures may be substantially larger and conformity rates lower as a result of incomplete documentation of NYHA class.

Use of the “Bogota Bag” for Temporary Abdominal Closure in Patients with Secondary Peritonitis

Various methods may be used for temporary closure of the abdomen. Use of the "Bogota bag" (BB) technique for abdominal closure has been reported primarily in the management of injuries. This review describes our experience using the BB technique in cases of secondary peritonitis. Abdomenal closure using BB was reviewed retrospectively in 152 patients with secondary peritonitis. Of the 152 cases of BB use reviewed, 79 patients had complications of previous abdominal operations, 57 had secondary peritonitis, 14 had complications of abdominal trauma, and 2 were cases of mesenteric events. The BB remained in situ from 1 to 19 days. Changes occurred between 1 and 11 times per patient (mean, 2.8). In nine patients, early diagnosis of leaking of small bowel content under the bag was noted, and 36 patients (24%) died from sepsis. In 12 patients, the resolution of abdominal sepsis permitted secondary closure 10 days later. In 16 patients, mesh repair was performed after 4 weeks. Musculocutaneal flap repair was used in one case, and 13 patients had skin grafts. Eleven patients eventually underwent ventral hernia repair. Early temporary closure of the abdominal wall using BB in patients with abdominal sepsis and planned re-explorations is simple, safe, inexpensive, and effective. This temporary abdominal cover provides good exposure of abdominal content between re-explorations and may prevent fistula formation. The development and subsequent repair of large hernias constitute one of the difficult postoperative problems requiring future solution.

Patterns of use and potential impact of early β-blocker therapy in non–ST-elevation myocardial infarction with and without heart failure: The Global Registry of Acute Coronary Events

Early beta-blocker (BB) therapy improves outcomes in ST-segment elevation myocardial infarction; however, limited data are available on its early use and its impact in non-ST-segment elevation myocardial infarction (NSTEMI). We evaluated data from 7106 patients with NSTEMI, without contraindications to BBs, enrolled in the Global Registry of Acute Coronary Events between April 1999 and September 2004. Baseline characteristics, management, and outcomes were analyzed according to the use of oral (+/-intravenous) BB within 24 hours of presentation. Multivariable analysis was conducted adjusting for comorbidities using the Global Registry of Acute Coronary Events risk model (c statistic 0.83). Beta-blocker therapy was initiated within the first 24 hours in 76% of patients with NSTEMI (79% with Killip class I vs 62% with class II/III; P < .001). Failure to initiate BBs within the first 24 hours was associated with lower rates of subsequent BB therapy (P < .001) and other evidence-based therapies. Early BB therapy was correlated with lower hospital mortality for NSTEMI patients (OR 0.58, 95% CI 0.42-0.81) and for those with Killip class II/III (OR 0.39, 95% CI 0.23-0.68) with a trend toward lower mortality in the Killip class I group (OR 0.77, 95% CI 0.49-1.21). At 6 months postdischarge, early BB use was associated with lower mortality in NSTEMI patients (OR 0.75, 95% CI 0.56-0.997) with a trend toward lower mortality in patients with Killip class I or II/III. Many eligible patients do not receive early BB therapy. Treatment with early BBs may have a beneficial impact on hospital and 6-month mortality in all patients, including those presenting with heart failure.

β-Blocker use in elderly ED patients with acute myocardial infarction

Background Despite the effectiveness of early β-blocker (BB) use in reducing mortality in acute myocardial infarction (AMI), they remain underutilized in the emergency department (ED) management of AMI. The elderly, with higher AMI mortality, and women, may be particularly vulnerable to underutilization of BB. Objective To determine the effect of age and gender on BB use in AMI in the ED. Methods A retrospective study of all ST-elevation AMI (STEMI) ED patients presenting to a community hospital ED from 2001 to 2003. Any contraindication to BB use (hypotension, bradycardia, AV block, active bronchospasm, and active congestive heart failure) was determined. Chi-square analysis was used to determine differences by gender and age. Results Three hundred eighty-five patients with STEMI were identified. Thirty-eight percent were women and 71% were over 60 years of age. Of the 270 (70%) who did not receive BB, 141 (52%) had contraindications to BB use. The total BB eligible group was 244 (63%). Of patients without contraindications to BB, 53% did not receive BB in the ED. By gender, 83 (54%) males and 46 (51%) females did not receive BB ( P= .669). By age, 96 subjects (59%) over age 60 and 33 subjects (41%) under age 60 did not receive BB ( P= .011). Conclusion Despite convincing evidence of effectiveness, BB remain underutilized in ED management of AMI, especially in the elderly. There does not appear to be a gender difference in BB use. Education programs should be directed towards emergency physicians regarding BB use in AMI, especially in elderly ED patients.

Quantification of creatine kinase BB isoenzyme in tumor cytosols and serum with an ultrasensitive time-resolved immunofluorometric technique

Objectives: To develop a highly sensitive immunofluorometric procedure for creatine kinase BB isoenzyme and use it to measure CK-BB in tumor cytosolic extracts and serum of cancer patients and healthy volunteers. Design and Methods: For assay development, we used two monoclonal antibodies in combination with time-resolved fluorometry and the biotin-avidin system. We measured CK-BB in breast tumor cytosols and studied its association with steroid hormone receptors. We also measured CK-BB in the serum of healthy subjects and patients with prostate cancer. We have examined the molecular weight of CK-BB in serum using high performance liquid chromatography. Results: The evaluation of the method revealed good precision and accuracy. Study of 336 breast tumor cytosols and 9 normal breast cytosols has shown that CK-BB is overexpressed by 95% of breast tumors and that CK-BB is present in its 80 kDa form. A close association between CK-BB and estrogen but not progesterone receptors was found, suggesting that CK-BB overexpression is another marker of estrogen sensitivity of these tumors. Previous studies, using CK-BB radioimmunoassay could not detect CK-BB in the serum of about 50% of healthy subjects. We have assessed CK-BB levels in 80 male volunteers, detected CK-BB in all sera and provided a detailed distribution of values. We further demonstrated that 30% of prostate cancer patients in remission (PSA < 0.4 μg/L) post radical prostatectomy and 50% of patients with active prostate cancer (PSA > 20 μg/L) have elevated serum CK-BB levels. The patients with highly elevated CK-BB also had highly elevated serum PSA. We have demonstrated that some patients who have elevated serum CK-BB also have macromolecular CK complexes in their serum with molecular weights of 700 and 350 kDa as well as the 80 kDa CK-BB isoenzyme. Only the latter was recognized by the assay developed. Conclusions: CK-BB is a marker of estrogen sensitivity in breast cancer; Patients with prostate cancer have elevated CK-BB in their serum; The new highly specific and sensitive assay may be further used to study the role of CK-BB in various malignancies.