Beta-blockers In Patients Research Articles

Current Use of Beta Blockers in Patients With Reactive Airway Disease Who Are Hospitalized With Acute Coronary Syndromes

Current Use of Beta Blockers in Patients With Reactive Airway Disease Who Are Hospitalized With Acute Coronary Syndromes

A Study of the Combined Effects of Exercise Training and a Beta Blocker in Patients With Chronic Heart Failure

A Study of the Combined Effects of Exercise Training and a Beta Blocker in Patients With Chronic Heart Failure

Leukocyte Redistribution: Effects of Beta Blockers in Patients with Chronic Heart Failure

BackgroundOverproduction of pro-inflammatory cytokines is a well established factor in the progression of chronic heart failure (CHF). Changes in cellular immunity have not been widely studied, and the impact of standard medication is uncertain. Here we investigate whether a leukocyte redistribution occurs in CHF and whether this effect is influenced by beta-blocker therapy.MethodologyWe prospectively studied 75 patients with systolic CHF (age: 68±11 years, left ventricular ejection fraction 32±11%, New York Heart Association class 2.5±0.7) and 20 age-matched healthy control subjects (age: 63±10 years). We measured the response of cells to endotoxin exposure in vitro, analysed subsets of lymphocytes using flow cytometry, and assessed plasma levels of the pro-inflammatory markers interleukin 1, 6, tumor necrosis factor-α, and soluble tumor necrosis factor receptors 1 and 2.Principal findingsWhile no differences in the number of leukocytes were noted between patients with CHF and healthy controls, we detected relative lymphopenia in patients with CHF (p<0.001 vs. control), mostly driven by reductions in T helper cells and B cells (both p<0.05). The number of neutrophils was increased (p<0.01). These effects were pronounced in patients who were beta-blocker naïve (32% of all patients with CHF). Increased plasma levels of soluble tumor necrosis receptor-1 correlated with the relative number of lymphocyte subsets.ConclusionsIn patients with CHF, we detected a redistribution of leukocyte subsets, i.e. an increase in neutrophils with relative lymphopenia. These effects were pronounced in patients who were beta-blocker naïve. The underlying mechanism remains to be elucidated.

Duplex Doppler Ultrasound Examination of the Portal Venous System: An Emerging Novel Technique for the Estimation of Portal Vein Pressure

Measurement of portal venous pressure in patients with portal hypertension is important to assess efficacy of beta blockers in patients with esophageal varices. Currently, the gold standard for measurement of portal venous pressure is the estimation of hepatic venous pressure gradient (HVPG). Being an invasive technique, serial measurements of HVPG are not feasible in clinical practice. In this respect, duplex Doppler ultrasound (DDUS) examination is an upcoming non-invasive technique for the estimation of portal venous and splanchnic hemodynamics. The aim of the present review is to analyze the current literature focusing on how the two techniques compare to each other in terms of assessing the portal pressure and assessing pitfalls in the current technique. Duplex Doppler ultrasound (DDUS) currently has limitations in measuring the portal pressure in a non-invasive way. Hemodynamic venous and arterial indices measured on DDUS correlate with the HVPG. The technique has been refined, however, there is no uniform surrogate marker that can be used in clinical practice. More studies are needed in order to remove the shortcomings in the current technique. The target is to be able to measure the actual portal pressure or at least derive an ideal venous or arterial hemodynamic surrogate marker having close correlation with the HVPG.

Beta Blockers for Peripheral Arterial Disease

To quantify the potential harm of beta blockers in patients with peripheral arterial disease. All randomised controlled trials (RCTs) comparing beta blockers with placebo for the outcomes of claudication and maximal walking distance and time, calf blood flow, vascular resistance and skin temperature were searched using the Cochrane Controlled Trials Register, PubMed and CINAHL. Trials comparing different types of beta blockers were excluded. Six RCTs fulfilling the above criteria, with a total of 119 patients, were included. The beta blockers studied were atenolol, propranolol, pindolol and metoprolol. None of the trials showed a statistically significant worsening effect of beta blockers on the outcomes measured. There were no reports of any adverse events with the beta blockers studied. Currently, there is no evidence to suggest that beta blockers adversely affect walking distance in people with intermittent claudication. Beta blockers should be used with caution if clinically indicated, especially in patients with critical ischaemia where acute lowering of blood pressure is contraindicated.

Role of beta‐blockers in patients admitted for worsening heart failure in a real world setting: data from the Italian Survey on Acute Heart Failure†

Randomized trials have shown that beta-blockers (BBs) reduce mortality in chronic heart failure (HF). Less data are available on the role of BBs in patients with acute HF, specifically if BBs should be continued or temporarily withdrawn. The aim of this study was to evaluate the role of BBs on in-hospital outcomes of patients admitted for worsening HF in a Cardiology setting. One thousand five hundred and seventy-two patients enrolled in the Italian Survey on Acute HF were evaluated. According to the BB therapy before and during hospitalization, four groups were defined: group A, no/no (51.6%); group B, no/yes (16.4%); group C, yes/no (9.0%); and group D, yes/yes (23.0%). Groups B and D had a significantly lower in-hospital mortality rate (group B 1.2%, group D 2.8%, group A 10.1%, and group C 12.1%; P < 0.0001). The association between non-use or withdrawal of BBs and higher mortality rate was confirmed by the multivariable analysis [group D, reference group; odds ratio (OR) 3.28, 95% confidence interval (CI) 1.47-7.32 and OR 4.20, 95% CI 1.59-11.10 for groups A and C, respectively], whereas no difference was found between groups B and D (OR 0.34, 95% CI 0.07-1.78). In patients hospitalized for worsening HF, non-use or discontinuation of BBs was associated with a significant higher mortality.

Current Use of Beta Blockers in Patients With Reactive Airway Disease Who Are Hospitalized With Acute Coronary Syndromes

Beta blockers have a proven benefit in the management of patients with acute coronary syndromes (ACS) and for secondary prevention of coronary events. Current guidelines list such reactive airway diseases (RADs) such as asthma and chronic obstructive pulmonary disease as relative contraindications to beta-blocker use. However, the co-morbid burden of RAD and coronary heart disease is substantial, and data suggest that the treatment benefit of beta blockers is shared by patients with RAD. The Get with the Guidelines (GWTG) database was used to evaluate use of beta blockers within 24 hours of admission and at discharge in patients with ACS with (n = 12,967) and without (n = 81,140) a history of RAD. Data were collected in 435 hospitals between January 2000 and September 2006. A multivariable logistic regression model was used to determine predictors of beta-blocker treatment. In patients with no RAD history, beta-blocker prescription rates were 78.3% at admission and 88.7% at discharge; in patients with a RAD history, rates were 65.6% at admission and 77.2% at discharge. Compared with patients with no history of RAD, patients with a history of RAD were 42% less likely (odds ratio 0.58, confidence interval 0.54 to 0.62, p <0.0001) to receive a beta blocker upon admission and 55% less likely (odds ratio 0.45, confidence interval 0.41 to 0.48, p <0.0001) to receive a beta blocker at discharge in multivariable analysis. Among all other clinical factors, RAD history was the most significant predictor of likelihood of not receiving a beta blocker at admission or discharge. Receipt of beta blockers within 24 hours after admission was associated with a lower in-hospital mortality rate for patients with RAD (odds ratio = 0.52, p <0.001) and for patients without RAD (odds ratio = 0.38, p <0.001). Careful assessment of beta-blocker safety and RAD severity by physicians is needed to improve beta-blocker prescription rates in this large group of patients with ACS.

Perioperative β blockers in patients having non-cardiac surgery: a meta-analysis

American College of Cardiology and American Heart Association (ACC/AHA) guidelines on perioperative assessment recommend perioperative beta blockers for non-cardiac surgery, although results of some clinical trials seem not to support this recommendation. We aimed to critically review the evidence to assess the use of perioperative beta blockers in patients having non-cardiac surgery. We searched Pubmed and Embase for randomised controlled trials investigating the use of beta blockers in non-cardiac surgery. We extracted data for 30-day all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke, heart failure, and myocardial ischaemia, safety outcomes of perioperative bradycardia, hypotension, and bronchospasm. 33 trials included 12 306 patients. beta blockers were not associated with any significant reduction in the risk of all-cause mortality, cardiovascular mortality, or heart failure, but were associated with a decrease (odds ratio [OR] 0.65, 95% CI 0.54-0.79) in non-fatal myocardial infarction (number needed to treat [NNT] 63) and decrease (OR 0.36, 0.26-0.50) in myocardial ischaemia (NNT 16) at the expense of an increase (OR 2.01, 1.27-3.68) in non-fatal strokes (number needed to harm [NNH] 293). The beneficial effects were driven mainly by trials with high risk of bias. For the safety outcomes, beta blockers were associated with a high risk of perioperative bradycardia requiring treatment (NNH 22), and perioperative hypotension requiring treatment (NNH 17). We recorded no increased risk of bronchospasm. Evidence does not support the use of beta-blocker therapy for the prevention of perioperative clinical outcomes in patients having non-cardiac surgery. The ACC/AHA guidelines committee should soften their advocacy for this intervention until conclusive evidence is available.

Beta blockers exposure and traumatic brain injury: a literature review

Traumatic brain injury (TBI) continues to carry a significant public health burden and is anticipated to worsen worldwide over the next century. Recently the authors of several articles have suggested that exposure to beta blockers may improve mortality rates following TBI. The exact mechanism through which beta blockers mediate this effect is unknown. In this paper, the authors review the literature regarding the safety of beta blockers in patients with TBI. The findings of several recent retrospective cohort studies are examined and implications for future investigation are discussed. Future questions to be addressed include: the specific indications for the use of beta blockers in patients with TBI, the optimal type and dose of beta blocker given, the end point of beta blocker therapy, and the safety of beta blockers in cases of severe TBIs.

Use of ACE Inhibitors / Angiotensive Receptor Blockers and Beta Blockers in Patients with Systolic Heart Failure with Associated Diagnosis of Chronic Kidney Disease

Backgound: Interdisciplinary care in an outpatient clinic (APN managed, physician directed) includes physical assessment, lab monitoring, education, and adherence to lifestyle modifications. This facilitates the initiation/titration of systolic heart failure (SHF) medication; ACE inhibitors / Angiotenson Receptor Blockers (ACEI/ARB) and Beta Blockers (BB) even in the presence of chronic kidney disease (CKD). The staff in the clinic consists of physician, nurses, dietitian, pharmacist, social work when needed. Medication titration with contraindications used as limiting factors in uptitration according to ACC/AHA guidelines were entered into an electronic data base. Comorbidities including diabetes and anemia were addressed and treated. Staff consistently worked with the attending physicians in the plan of care. Patients are referred to the clinic by their internal medicine physician or cardiologist. Method: 107 patients with SHF active in year 2007 were analyzed, average age 73 years, 42% female. Subset of 88 (80%) patients had CKD stages 3–5, average estGFR 34.18 (range 10–15). Using a set of protocols, patients were seen as often as necessary for assessment, symptom management, monitoring lab data, and adherence concerns. Attention was paid to changes in potassium level and creatinine/est GFR. Data was analyzed for ACEI/ARB and BB use and target doses. Patient target was defined as maximum dose after repeated attempts to uptitrate to ACC/AHA guidelines or maximum dose tolerated within safe guidelines. Results: Of the 88 patients with CKD: 86% (76) were on ACEI/ARB, of those on ACEI/ARB 71% (54) reached target doses; 96.6% (85) were on BB, of those on BB, 65.9% (56) reached a target dose. The most limiting factor in ACEI/ARB use was potassium levels, change in creatinine levels, and symptomatic hypotension in the presence of euvolemia. The limiting factor in BB use was symptomatic hypotension also in euvolemic patients. A smaller percentage of limiting factors were renal artery stenosis and physician choice not to uptitrate. Conclusion: Patients with SHF and CKD can be placed on recommended medications with close monitoring. KDOKI guidelines in renal disease now recommend the use of ACEI/ARB use in chronic kidney disease. Continuing efforts are made to place patients on appropriate medications at maximum doses and educate our staff and attending physicians to the benefits of ACEI/ARB for renal protection and BB in patients with SHF and renal disease. Backgound: Interdisciplinary care in an outpatient clinic (APN managed, physician directed) includes physical assessment, lab monitoring, education, and adherence to lifestyle modifications. This facilitates the initiation/titration of systolic heart failure (SHF) medication; ACE inhibitors / Angiotenson Receptor Blockers (ACEI/ARB) and Beta Blockers (BB) even in the presence of chronic kidney disease (CKD). The staff in the clinic consists of physician, nurses, dietitian, pharmacist, social work when needed. Medication titration with contraindications used as limiting factors in uptitration according to ACC/AHA guidelines were entered into an electronic data base. Comorbidities including diabetes and anemia were addressed and treated. Staff consistently worked with the attending physicians in the plan of care. Patients are referred to the clinic by their internal medicine physician or cardiologist. Method: 107 patients with SHF active in year 2007 were analyzed, average age 73 years, 42% female. Subset of 88 (80%) patients had CKD stages 3–5, average estGFR 34.18 (range 10–15). Using a set of protocols, patients were seen as often as necessary for assessment, symptom management, monitoring lab data, and adherence concerns. Attention was paid to changes in potassium level and creatinine/est GFR. Data was analyzed for ACEI/ARB and BB use and target doses. Patient target was defined as maximum dose after repeated attempts to uptitrate to ACC/AHA guidelines or maximum dose tolerated within safe guidelines. Results: Of the 88 patients with CKD: 86% (76) were on ACEI/ARB, of those on ACEI/ARB 71% (54) reached target doses; 96.6% (85) were on BB, of those on BB, 65.9% (56) reached a target dose. The most limiting factor in ACEI/ARB use was potassium levels, change in creatinine levels, and symptomatic hypotension in the presence of euvolemia. The limiting factor in BB use was symptomatic hypotension also in euvolemic patients. A smaller percentage of limiting factors were renal artery stenosis and physician choice not to uptitrate. Conclusion: Patients with SHF and CKD can be placed on recommended medications with close monitoring. KDOKI guidelines in renal disease now recommend the use of ACEI/ARB use in chronic kidney disease. Continuing efforts are made to place patients on appropriate medications at maximum doses and educate our staff and attending physicians to the benefits of ACEI/ARB for renal protection and BB in patients with SHF and renal disease.

Effect of Beta-Blocker Therapy on Survival in Patients With Severe Mitral Regurgitation and Normal Left Ventricular Ejection Fraction

Chronic volume overload from chronic severe mitral regurgitation (MR) results in neuroendocrine activation similar to the heart failure syndrome despite normal left ventricular (LV) ejection fraction (EF). Hence, the hypothesis that beta-blocker (BB) therapy may have a beneficial effect in these patients was tested using a large observational cohort. Our echocardiographic database was searched for patients with severe MR and normal LVEF. Full chart reviews were conducted for clinical and pharmacologic data. Survival was analyzed as a function of BB therapy. The search produced 895 patients aged 68 +/- 17 years, 44% men, with LVEF 66 +/- 7%. Of these, 32% were on BB therapy. Use of a BB was associated with a significantly decreased mortality hazard of 0.62 (95% confidence interval 0.46 to 0.83, p = 0.002), which was unchanged after adjusting for age, gender, LVEF, coronary artery disease, diabetes mellitus, hypertension, and cardiac valve surgery. The independent beneficial effect of BBs was seen in patients with or without coronary artery disease, those with or without hypertension, and patients managed both medically and surgically. In conclusion, use of BB therapy was associated with a significant independent survival benefit in patients with chronic severe MR with normal LVEF. This benefit was seen in patients with or without coronary artery disease, as well as patients managed both medically and surgically. Use of BBs in patients with severe MR despite normal LVEF is suggested.

Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial

Trials of beta blockers in patients undergoing non-cardiac surgery have reported conflicting results. This randomised controlled trial, done in 190 hospitals in 23 countries, was designed to investigate the effects of perioperative beta blockers. We randomly assigned 8351 patients with, or at risk of, atherosclerotic disease who were undergoing non-cardiac surgery to receive extended-release metoprolol succinate (n=4174) or placebo (n=4177), by a computerised randomisation phone service. Study treatment was started 2-4 h before surgery and continued for 30 days. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal cardiac arrest. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00182039. All 8351 patients were included in analyses; 8331 (99.8%) patients completed the 30-day follow-up. Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint (244 [5.8%] patients in the metoprolol group vs 290 [6.9%] in the placebo group; hazard ratio 0.84, 95% CI 0.70-0.99; p=0.0399). Fewer patients in the metoprolol group than in the placebo group had a myocardial infarction (176 [4.2%] vs 239 [5.7%] patients; 0.73, 0.60-0.89; p=0.0017). However, there were more deaths in the metoprolol group than in the placebo group (129 [3.1%] vs 97 [2.3%] patients; 1.33, 1.03-1.74; p=0.0317). More patients in the metoprolol group than in the placebo group had a stroke (41 [1.0%] vs 19 [0.5%] patients; 2.17, 1.26-3.74; p=0.0053). Our results highlight the risk in assuming a perioperative beta-blocker regimen has benefit without substantial harm, and the importance and need for large randomised trials in the perioperative setting. Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol.

Abstract 3468: Perioperative Betablockers Reduce Cardiovascular events in Patients Undergoing High Risk Non-cardiac Surgery-A Meta-analysis

Introduction: ACC/AHA 2006 guidelines recommend perioperative beta blockers(BB) for high risk cardiac patients (class IIa), intermediate and low cardiac risk patients (class IIb) undergoing non-cardiac surgery. Meta-analysis of trials on perioperative blockers up to April 2003 found insufficient evidence for reduction of major cardiovascular events. We analysed the current evidence on effects of perioperative beta-blockers in patients not on BB and undergoing non-cardiac surgery. Materials and Methods: We did a literature search for randomized placebo controlled clinical trials of perioperative beta blockers in patients undergoing high risk non-cardiac surgery. End points were 30 day total mortality, cardiovascular mortality, perioperative cardiovascular outcomes, non-fatal MI, unstable angina, ventricular tachycardia, congestive heart failure, non-fatal stroke,non-fatal cardiac arrest,hypotension, bradycardia, bronchospasm. Data was extracted on an intention-to-treat basis. Heterogeneity of the studies was analyzed by Cochran’s Q statistics. The Mantel-Haenszel fixed-effect model was used to calculate combined relative risks for outcomes. Results: 24 studies with 3454 patients were included. Perioperative BB showed statistically significant benefit in reducing perioperative cardiovascular events and non-fatal MI and a nominally statistically significant benefit for cardiovascular mortality. The other end points were not significantly different between the two treatment groups. The results are summarized in the table below. Conclusion: Perioperative beta blockers reduce cardiovascular events and their use is recommended in all patients without contraindications and undergoing non-cardiac surgery.

The Preoperative Electrocardiogram

The Preoperative Electrocardiogram

Analyse des fréquences cardiaques durant la période péri-opératoire chez des patients prenant des bêtabloquants : réalité et efficacité du traitement

Objective To compare perioperative heart rate (HR) control of patients chronically exposed to beta-blockers (BB) with those of patients whom BB treatment was initiated one week preoperatively. Methods HR was noticed at three successive time periods: the anaesthesia visit, just before induction of anaesthesia, and during surgery (maximum and minimum HR). HR, presented as mean ± SD, was compared among 3 groups of patients: BB chronic treatment, preoperative BB, and a control group not taking BB. Results Four hundred (and) six patients were included: 181 chronic BB patients, 20 preoperative BB, and 205 control patients. As compared to the control group, HR of chronic BB patients were lower ( P < 0.05) than those of the control group at the three time period of the study. In the preoperative BB patient group, one week BB treatment resulted in a mean 30% reduction of HR. Just before induction of anaesthesia, HR of preoperative BB patients was lower than that of chronic BB patients (55 ± 11 vs 67 ± 13 b/min; P < 0.05). Conclusion Beta-blockers treatment initiated one week before surgery could be more effective on perioperative HR control than chronic BB treatment.

Perioperative beta-blocker therapy and mortality after major non cardiac surgery

Conclusion: Perioperative beta-blocker therapy reduces risks of in-hospital death in high-risk patients undergoing major non-cardiac surgery. Summary: The authors conducted a retrospective cohort study of patients >18 years of age undergoing major non-cardiac surgery in the years 2000 and 2001 in 329 hospitals in the United States. The aim was to assess the use of perioperative beta blockers and their effects on in-hospital mortality as used in routine clinical practice. Propensity scoring matching was used to adjust for differences in patients who received and who did not receive perioperative beta blockers. In-hospital mortality was compared using multivariable logistic modeling. Surgical procedures were categorized using available DRG software. The procedure was considered major if the median length of stay by diagnostic group exceeded two days. Information was recorded regarding age, sex, race, ischemic heart disease, congestive heart failure, cerebrovascular disease, renal insufficiency, diabetes, hyperlipidemia and hypertension. Other perioperative medications such as angiointensin converting enzyme inhibitors, calcium channel blockers, and antiplatelet agents and methods of venous prophylaxis were also recorded. Contraindications to beta blocker therapy were assessed. There were 782,969 patients analyzed; 85% apparently had no contraindication to beta blockers. 18% (n = 122,338) received beta blocker therapy in the first two hospital days. Fourteen percent of patients had a revised cardiac risk index (RCRI) score of 0 and 44% had a score of 4 or higher. Risk of death related to perioperative beta-blocker treatment varied directly with cardiac risk. In 580,665 patients with a RCRI score of 0 or 1 there was no benefit from perioperative beta-blockers. Among patients with a RCRI score of 2, 3, or 4, adjusted odds ratio for death in the hospital were 0.88 (95% CI, 0.8 to 0.98), 0.71 (95% CI, 0.63 to 0.80), and 0.58 (95% CI, 0.50 to 0.67), respectively. Comment: Only approximately 51,000 of the patients analyzed in this study underwent a vascular surgical procedure. Nevertheless, vascular patients generally have increased cardiac risk and the results of this study support strongly the use of beta blockers in patients with high cardiac risk. There is no question that the perioperative use of beta-blockers as a routine in vascular surgical patients without contraindications to beta blocker therapy should be standard practice.

Beta Blockade in Diabetic Heart Failure

The pathophysiologic effects of diabetes on the heart occur, in part, through activation of the sympathetic nervous system. To date, no randomized clinical trial has investigated beta blocker therapy prospectively in a population of patients who have diabetes and HF. The question of the efficacy of beta blockers in patients who have diabetes and HF and the concern over adverse metabolic effects has limited the use of these agents in this patient population. Clinical trial evidence and recent meta-analysis data confirm the efficacy of specific beta blockers in patients who have HF and diabetes. In addition, negative metabolic effects have not been seen with the use of the nonselective agent carvedilol. Therefore, in the absence of contraindications, beta blockade should not be withheld in treating patients who have diabetes and HF; and their use may be instrumental in preventing further progression of HF and death in this population.

Under-use of beta-blockers in patients with ischaemic heart disease and concomitant chronic obstructive pulmonary disease

Beta-blockers (BB) improve morbidity and mortality in ischaemic heart disease. There is a general reluctance to use BB, especially in patients with chronic obstructive pulmonary disease (COPD), which is perceived as an absolute contraindication. As large numbers of patients are labelled with COPD without objective evidence, they may miss out on the benefit from these drugs. To assess the use of BB in patients with COPD admitted with acute coronary syndrome (ACS), and to assess the supporting evidence for the diagnosis of COPD in these patients. Case-note review and retrospective analysis of 457 consecutive patients admitted with troponin-positive ACS between October 2002 and October 2003. Of 457 ACS patients studied, 246 (54%) were discharged on a BB. Cardiologists prescribed BB in ACS patients more frequently than did general physicians, (70% vs. 30%, respectively). The reasons for withholding BB were: not documented 27%, COPD 33%, heart failure 24%, others 16%. Ninety-four patients (21%) had a diagnosis of COPD; only 58 (62%) of these had been reviewed by a chest physician or had previous pulmonary function tests. Of the 94 patients with COPD, only 15 (16%) were prescribed BB during the admission: 9 by cardiologists and 6 by non-cardiologists. BB were discontinued in two patients due to an increase in dyspnoea. Many patients with a diagnosis of COPD have no objective evidence to support the diagnosis and are denied the prognostic benefits of BB when presenting with ACS. Before withholding beta-blockers, COPD and reversibility should be ascertained by pulmonary function testing. The overall use of beta-blockers remains sub-optimal and could be improved in this setting.

Administration périopératoire de bêtabloquants : enquête de pratique

To evaluate the anaesthesiologists' attitude concerning the perioperative administration of betablockers (BB), especially prophylactic BB, in order to prevent postoperative cardiac complications. A questionnaire including 20 items was sent to 700 anaesthesiologists of 4 French departments (Ain, Isere, Loire et Rhone). The response rate was 30%. Eighty-eight percent of respondents prescribed the BB with the premedication, on the day of the surgery in patients who were on regular BB. Before major surgery, 37% percent of respondents always or usually introduced prophylactic BB in patients with high cardiac risk. Atenolol was the drug of choice for 68% of perioperative BB users. Seventy-one percent of anaesthesiologists using prophylactic BB asked for a cardiologic opinion before starting BB therapy. In practice, anaesthesiologists continued BB during the perioperative period in patients who were on chronic treatment with BB. However, prophylactic perioperative administration of BB in patients with high cardiac risk is still inadequate and dependent on a cardiologic opinion.

Use of Beta Blockers in Patients with Post-MI Left Ventricular Dysfunction.

beta Blockers have been shown to reduce mortality after myocardial infarction (MI) in several large trials. Despite strong evidence supporting the role of beta blockers in treating patients after MI, less than half are prescribed these drugs. The majority of studies demonstrating efficacy of beta blockers in the treatment of the post-MI patients were conducted at a point in time when left ventricular (LV) dysfunction was considered a strong contraindication to their use. In addition, when these studies were carried out a variety of therapies that are known to improve survival were not yet available. In the present era, beta blockers are routinely used to treat patients with heart failure due to systolic dysfunction. Until recently, however, there was uncertainty about their role in the management of patients with LV dysfunction after MI. The recent CAPRICORN (Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction) study demonstrated a significant mortality benefit when carvedilol was added to standard therapy in patients with LV dysfunction after MI. This article reviews information regarding the initiation and maintenance of beta blockers in patients with post-MI LV dysfunction.