Use Of Beta-blockers In Patients Research Articles

(433) - Beta Blocker Use in Patients with LVADs Is Associated with Lower proBNP and Is Not Associated with Heart Failure Hospitalizations or an Increase in Adverse Events

While Beta Blockers (BB) are recognized as important in management of advanced heart failure, use of BB post left ventricular assist device (LVAD) implantation remains controversial. Concern has been raised about the possible effects of BB on right ventricular function post LVAD implantation. The purpose of this study was to evaluate the safety of BB use post LVAD implantation.

Use of Antiarrhythmic Medications in Medicare Part D Patients With an Implantable Cardioverter-Defibrillator and Ventricular Tachycardia

Ventricular tachycardia (VT) is common in cardiomyopathy patients with an implantable cardioverter-defibrillator. This analysis evaluated antiarrhythmic medication use and change in use over time in patients with VT and structural heart disease. Query of Medicare claims identified patients with an implantable cardioverter-defibrillator and VT. Patients with atrial fibrillation or supraventricular tachycardia were excluded. Two cohorts were created of patients enrolled in Medicare Part D for the 12months before 2007 and 2012. Patients were identified through a search for antiarrhythmic medication fills with a supply covering January 1 of the cohort year. Adjusted logistic regression modeling evaluated the association between patient characteristics and antiarrhythmic medication use. The 2007 (n= 2,334) and 2012 (n= 3,892) Medicare Part D cohorts had similar demographics: median age 76years, 64%-67% male, and 87%-89% white. Of the 2007 cohort, 1,380 (59%) patients were on a beta blocker, and 484 (20.7%) were on an antiarrhythmic medication (70% amiodarone and 20% sotalol). Between 2007 and 2012, there was a statistically significant higher use of any antiarrhythmic medication (p= 0.014), beta blockers (p<0.0001), mexiletine (p= 0.005), and ranolazine (p <0.0001), while amiodarone use remained unchanged (p= 0.53). After multivariable adjustment, male gender and renal disease were associated with higher antiarrhythmic medication use. In conclusion, although antiarrhythmic medication and beta blocker use in patients with VT increased over time, <1in 4 patients were on an antiarrhythmic medication and only 65% of the patients were on a beta blocker.

Is perioperative beta-blockade effective and safe in patients undergoing noncardiac surgery?

Beta-blockade in patients undergoing noncardiac surgery has been widely recommended as a way to reduce cardiovascular adverse events during the perioperative period. However, studies have shown contradictory results. Searching in Epistemonikos database, which is maintained by screening multiple databases, we identified 22 systematic reviews comprising 131 studies addressing the question of this article, including 112 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded perioperative use of beta-blockers in patients undergoing noncardiac surgery, although probably decreases the risk of myocardial infarction, increases the risk of stroke and total mortality.

Beta-blockers are under-prescribed in patients with chronic obstructive pulmonary disease and co-morbid cardiac disease.

The use of beta-blockers in patients with chronic obstructive pulmonary disease and co-morbid cardiovascular disease is controversial, despite increasing evidence to support their use as safe and efficacious. This study retrospectively assessed the rates of beta-blocker prescription in patients admitted to two Australian tertiary hospitals for acute exacerbation of chronic obstructive pulmonary disease. This revealed that less than half of patients (45%) with known cardiac indications were receiving beta-blocker therapy, evident across all degrees of airways disease severity. Further work is needed to ensure that medical management of this patient group is optimised.

PP.14.07] PREOPERATIVE PREDICTIVE FACTORS FOR NON-VALVULAR POSTOPERATIVE ATRIAL FIBRILLATION IN PATIENTS UNDERGOING CORONARY BYPASS SURGERY (ON-PUMP VERSUS OFF-PUMP)

Objective: Postoperative atrial fibrillation (POAF) after isolated coronary revascularization is the most frequent rhythm disorder after cardiac surgery, with a reported incidence between 10% and 40%, associated with hemodynamic instability, increased morbidity and mortality. The aim of this study was to identify significant preoperative predictors for non-valvular POAF in patients undergoing on-pump and off-pump coronary artery surgery. Design and method: Retrospective study included 226 consecutive patients revascularized at Clinic of Cardiac Surgery, Clinical Center of Serbia, between September and December 2014. Patients were divided in two groups: on-pump (N: 176) and off-pump (N: 50). In both groups, we investigated the association of preoperative factors (gender, age, body mass index [BMI], type of coronary artery disease [CAD], left ventricular systolic function, preoperative angina pectoris [AP] and myocardial infarction [MI], preoperative size of the left atrium and left ventricle, degree of mitral regurgitation [MR], arterial hypertension, diabetes, hyperlipidemia, chronic lung disease, preoperative transient ischemic attack or cerebrovascular insult, peripheral arterial disease and smoking) with the occurrence of non-valvular POAF, using the Logistic regression analysis. Exclusion criteria were severe MR and preoperative AF. Results: The incidence of POAF was 23.45% (on-pump: 22.2%, off-pump: 28%; p > 0.05). There were statistically significant differences between two study groups considering: type of CAD (X2 = 5,030; p = 0,026), left ventricular systolic function (X2 = 12,896; p < 0,001), preoperative MI (X2 = 6,668; p = 0,010), preoperative size of the left atrium (X2 = 13,046; p < 0,001) and left ventricle (EDD: t = 3,439; p = 0,001, ESD: t = 3,162; p = 0,002) and presence of diabetes mellitus (X2 = 6,841; p = 0,009). In the off-pump group, an independent preoperative predictor of POAF was preoperative size of left atrium (OR 34.000; 95% CI 1.479–781.787; p: 0.027). We found that patients with very enlarged left atrium (>5 cm) had significantly higher risk of POAF. Paradoxically, an independent inverse relationship of preoperative arterial hypertension and the risk of POAF was documented in the on-pump group (OR 0.088; 95% CI 0.009–0.874; p: 0.038), most likely due to the more frequent preoperative use of beta-blockers in patients with a history of hypertension. Conclusions: Independent preoperative predictors for POAF are preoperative size of left atrium in off-pump and arterial hypertension in on-pump revascularized patients.

Predictors, Trends, and Outcomes (Among Older Patients ≥65 Years of Age) Associated With Beta-Blocker Use in Patients With Stable Angina Undergoing Elective Percutaneous Coronary Intervention

This study sought to examine predictors, trends, and outcomes associated with β-blocker prescriptions at discharge in patients with stable angina without prior history of myocardial infarction (MI) or systolic heart failure (HF) undergoing elective percutaneous coronary intervention (PCI). The benefits of β-blockers in patients with MI and/or systolic HF are well established. However, whether β-blockers affect outcomes in patients with stable angina, especially after PCI, remains uncertain. We included patients with stable angina without prior history of MI, left ventricular systolic dysfunction (left ventricular ejection fraction<40%) or systolic HF undergoing elective PCI between January 2005 and March 2013 from the hospitals enrolled in the National Cardiovascular Data Registry (NCDR) CathPCI registry. These patients were retrospectively analyzed for predictors and trends of β-blocker prescriptions at discharge. All-cause mortality (primary endpoint), revascularization, or hospitalization related to MI, HF, or stroke at 30-day and 3-year follow-up were analyzed among patients≥65 years of age. A total of 755,215 patients from 1,443 sites were studied, and 71.4% population of our cohort was discharged on β-blockers. At 3-year follow-up among patients≥65 years of age with CMS data linkage (16.3% of the studied population), there was no difference in adjusted mortality rate (14.0% vs. 13.3%; adjusted hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.96 to 1.03; p= 0.84), MI (4.2% vs. 3.9%; adjusted HR: 1.00; 95% CI: 0.93 to 1.07; p= 0.92), stroke (2.3% vs. 2.0%; adjusted HR: 1.08; 95% CI: 0.98 to 1.18; p= 0.14) or revascularization (18.2% vs. 17.8%; adjusted HR: 0.97; 95% CI: 0.94 to 1.01; p= 0.10) with β-blocker prescription. However, discharge on β-blockers was associated with more HF readmissions at 3-year follow-up (8.0% vs. 6.1%; adjusted HR: 1.18; 95% CI: 1.12 to 1.25; p< 0.001). Results at 30-day follow-up were broadly consistent as well. During the period between 2005 and 2013, there was a gradual increase in prescription of β-blockers at the index discharge in our cohort (p< 0.001). Among patients≥65 years of age with history of stable angina without prior MI, systolic HF or left ventricular ejection fraction<40% undergoing elective PCI, β-blocker use at discharge was not associated with anyreduction in cardiovascular morbidity or mortality at 30-day and at 3-year follow-up. Over time, β-blockers useatdischarge in this population has continued to increase.

An About-Face on Beta-Blocker Use in Decompensated Cirrhosis

Beta-blocker use in patients with severe decompensated cirrhosis may increase mortality (NEJM JW Gastroenterol Aug 2014 and Gastroenterology 2014;

Non-Selective Beta-Blockers in Liver Cirrhosis: Friends or Foes? A Review of the Literature

Cirrhosis has become a leading cause of death in the United States and worldwide owing the increased prevalence of alcoholic liver disease, hepatitis C, and more recently, non-alcoholic steatohepatitis and non-alcoholic fatty liver disease. Beta-blockers have been proven to be efficacious in primary, as long as secondary prophylaxis of variceal bleeding, more than 35 years ago. Nonetheless, recent data has cautioned the use of beta-blockers in patients with end-stage cirrhosis and refractory ascites suggesting increased mortality from beta-blockers in this group of patients. In this article, we will discuss this topic in details, and review the conflicting studies about beta-blockers in cirrhosis, and try to provide logical suggestions concerning the use of this class of medication in patients with cirrhosis.

Do beta-blockers worsen respiratory status in patients with COPD?

Evidence-Based Answer Use of beta-blockers in patients with mild to moderate chronic obstructive pulmonary disease (COPD) does not adversely affect forced expiratory volume in 1 second (FEV1), symptoms, or beta-agonist response (SOR: A, meta-analysis). The effect on mortality is mixed. In COPD populations with high prevalence of heart failure and vascular disease, beta-blockers (predominantly noncardioselective beta-blockers) are associated with decreased mortality (SOR: B, systematic review of cohort studies and single cohort study). In patients with more severe, oxygen-dependent COPD, beta-blockers may be associated with increased mortality (SOR: C, cohort study).

Elucidating the role of incidental use of beta-blockers in patients with metastatic brain tumors in controlling tumor progression and survivability.

Beta-adrenergic antagonists have demonstrated beneficial effects in tumor progression and survivability in patients with various cancers by inhibiting norepinephrine-induced tumor cell migration. However, little is known about their effects on the outcomes of metastatic brain tumors (MBTs). This study was undertaken to evaluate the effects of beta-blockers, if any, on the outcome of MBTs, and their possible role in controlling tumor progression and survivability. A retrospective cohort analysis of 225 patients identified as having MBTs presenting to our institution from 2001 through 2013 was conducted by reviewing electronic patient records. Patients were categorized into three groups: Group A comprised hypertensives on beta-blockers only (40, 18%), Group B comprised hypertensive patients on antihypertensive medications other than beta-agonists (65, 29%), and Group C comprised normotensives (120, 53%). All outcomes were compared using the data on pre - and post-gamma knife radiosurgery (GKRS) for these groups. One-way analysis of variance (ANOVA) was used to compare the radiological and clinical outcomes in the patient population following beta-blockers usage in Group A versus groups B and C. Cox regression model was used to demonstrate prognostic factors for the outcome in patients having different primaries. Overall survival period was plotted on Kaplan-Meier curves. The log-rank (Mantel-Cox) test was used to analyze the survival difference in the cases. P < 0.05 was considered significant. The mean age of patients was 57.34 ± 10.98 years (range: 30-87 years) and 44% were males. More than half (130/225, 58%) of patients with MBT had their primary tumor source in the lung, 16% in the breast, and 7% each in the kidneys and the rectum. Frontal lobe was the most commonly affected (80, 35.5%). Statistically significant control of tumor growth (P = 0.001), tumor progression (P = 0.0001), and higher survival outcomes (P = 0.015) were observed in Group A as compared to other groups. In comparing the different groups, breast primaries showed the strongest correlation to survival benefit (P = 0.049) from beta-blocker usage as a primary antihypertensive medication. Concomitant use of beta-blockers with conventional therapy may offer potential benefit to hypertensive patients developing MBTs by ameliorating tumor progression and conferring a survival advantage. This effect was most notable in patients with primary tumors originating in the breast. Prospective studies, molecular research, and randomized controlled trials are warranted to further explore this promising effect.

Beta-blockers reduced the risk of mortality and exacerbation in patients with COPD: a meta-analysis of observational studies.

BackgroundCardiovascular disease is a primary cause of death in patients with chronic obstructive pulmonary disease (COPD). Beta-blockers have been proved to reduce morbidity and improve survival in patients with cardiac diseases. But the effects of beta-blockers on outcomes in patients with COPD remain controversial. The objective of this meta-analysis was to assess the effect of beta-blockers on mortality and exacerbation in patients with COPD.MethodsAn extensive search of the EMBASE, MEDLINE and Cochrane was performed to retrieve the studies of beta-blockers treatment in patients with COPD. The random effects model meta-analysis was used to evaluate effect on overall mortality and exacerbation of COPD.ResultsFifteen original observational cohort studies with a follow-up time from 1 to 7.2 years were included. The results revealed that beta-blockers treatment significantly decreased the risk of overall mortality and exacerbation of COPD. The relative risk (RR) for overall mortality was 0.72 (0.63 to 0.83), and for exacerbation of COPD was 0.63 (0.57 to 0.71). In subgroup analysis of COPD patients with coronary heart disease or heart failure, the risk for overall mortality was 0.64 (0.54–0.76) and 0.74 (0.58–0.93), respectively.ConclusionThe findings of this meta-analysis confirmed that beta-blocker use in patients with COPD may not only decrease the risk of overall mortality but also reduce the risk of exacerbation of COPD. Beta-blocker prescription for cardiovascular diseases needs to improve in COPD patients.

Swept away and squashed between myth based medicine and eminence based medicine. Metaphor of medical meta-cognition. What are we doing wrong with our patient?

Myths have played essential social functions throughout human history, and modern medical culture makes no exception. Despite ongoing scientific efforts, clinicians still encounter biological phenomena that they can hardly explain. In this ocean of uncertainty they continue, either consciously or unconsciously, to convey a number of myths, which are also used as professional tools. Although in recent decades clinical research and randomized trials have emerged as the main arbiters of truth in medicine, there are still large areas of uncertainty that are consistently filled up with tradition, common sense and experience. In this context, mysticism seldom represent a latent source of error, especially when it penetrates education and medical literature, so growing to the role of indisputable truth, which can hardly be eradicated. The aim of this article is to discuss some paradigmatic examples of medical myths, such as the use of beta-blockers in patients with heart failure, the risk of administering opioids in patients with abdominal pain, the suggestion to drink at least eight glasses of water per day, the risk of using contrast media in patients with shellfish allergy, the indiscriminate prescription of a huge number of laboratory tests to achieve an efficient diagnosis, the use of garlic for treat a kaleidoscope of human disorders, fructose as a viable replacement for sucrose, the relationship between obesity and mortality or between sex and caloric consumption, and the cognitive biases.

Invited Commentary

The leading cause of death in the United States remains heart disease. Coronary artery bypass graft (CABG) surgery remains a mainstay therapy in the treatment of this condition. Patients who have coronary artery disease are often smokers and therefore frequently have a concurrent diagnosis of chronic obstructive pulmonary disease (COPD). Published incidence of patients undergoing CABG who also have COPD range from 4% to 27%. Because of the possible bronchoconstrictive effects of beta-blockers, the use of these agents in patients with COPD undergoing CABG has previously been contraindicated. It is well known that the use of beta-blockers in patients undergoing CABG provide both a survival benefit and a protective effect to the development of postoperative atrial fibrillation. This study published by Angeloni and colleagues [1Angeloni E. Melina G. Roscitano A. et al.β-blockers improve survival of patients with chronic obstructive pulmonary disease after coronary artery bypass grafting.Ann Thorac Surg. 2013; 95: 525-532Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] in this issue of The Annals of Thoracic Surgery investigates the long-term survival of patients with COPD undergoing CABG. Patients receiving beta-blockers before and after CABG surgery were compared to those patients who did not receive beta-blockers. Although this was not a randomized controlled trial, the authors attempt to circumvent this limitation by using propensity-matched controls to account for any baseline differences between the groups. At a median follow-up of 36 months, there was a highly significant survival advantage in the beta-blocker group (7.7% deaths) compared to the non–beta-blocker group (18.3% deaths). Surprisingly, there was no difference in the incidence of COPD exacerbations during this time period. This study is the first to compare the effects of beta-blockers on the long-term survival of COPD patients undergoing CABG surgery. Because this study did not stratify based on the severity of COPD, future studies could examine the potential effects of the degree of COPD and outcomes of CABG surgery of patients both with and without beta-blocker therapy. This study carries significant clinical implications for both the preoperative and postoperative management of patients with COPD undergoing CABG. Clinicians providing care for these critically ill patients can prescribe beta-blockers with the knowledge that these medications have significant protective effects on long-term survival without the potential for COPD exacerbations. β-Blockers Improve Survival of Patients With Chronic Obstructive Pulmonary Disease After Coronary Artery Bypass GraftingThe Annals of Thoracic SurgeryVol. 95Issue 2Previewβ-Blockers are known to improve survival of patients with cardiovascular disease, but their administration in patients with chronic obstructive pulmonary disease (COPD) remains controversial. The aim of the present study was to assess the effect of β-blocker administration in patients with COPD undergoing coronary artery bypass grafting. Full-Text PDF

USE OF BETA-BLOCKERS IN THE PERIOPERATIVE PERIOD: HOW STRONG ARE THE EVIDENCES?

Optimization of the pharmacotherapy in preoperative period is the cornerstone of the concept of risk modification of cardiovascular complications in the perioperative period. Therefore, special attention has recently been focused on the use of beta-blockers in the postoperative period. Nowadays convincing evidence base for the use of this class of drugs in the perioperative period that was the basis for the development of clinical guidelines is accumulated. Moreover, results of large randomized trials of beta-blockers are controversial. This has resulted in significant differences in the classes of recommendations and levels of evidence. Analysis of the results of basic researches and the provisions of recommendations of the international and national professional medical societies on the use of beta-blockers in patients with cardiovascular disease to reduce the risk of cardiac complications in the perioperative period for planned extracardiac surgical procedures is presented.

Incidence and trends of heart failure admissions after coronary artery bypass grafting surgery

Factors related to hospitalization for heart failure (HF) following coronary artery bypass grafting (CABG) surgery were studied. Patients (n = 65 377) undergoing CABG surgery in New Jersey from 1998 to 2007 were identified from the state cardiac surgery database; subsequent hospitalizations for HF were assessed using the Myocardial Infarction Data Acquisition System database. Patients were classified based on pre-operative ejection fraction (EF). Multivariate models were used to identify factors related to HF admission and mortality. Post-CABG HF admission rates among patients with pre-operative EF <35% increased over the 10-year period (P = 0.02), but no significant trend was seen among patients with EF ≥35%. Independent factors associated with post-CABG HF admission within 2 years were: EF, age, female gender, Black race, smoking, diabetes, renal disease, hypertension, and cerebrovascular disease. Pre-operative use of beta-blockers increased over the years (P < 0.0001) and reduced the risk of admission for HF by 13%, with greater benefit in patients with lower EF. Mortality remained unchanged from 1998 to 2007, averaging 1.8% in-hospital and 5.1% and 7.2% at 1-year and 2-year follow-up, respectively. Pre-operative EF is a strong predictor of HF admission within 2 years after CABG surgery. The use of beta-blockers decreased HF admission after CABG, especially in patients with EF <35%. Despite the more pronounced benefit and increasing use of beta-blockers in patients with a low EF, HF admission rates in this group of patients are rising. This suggests that more comprehensive management of factors associated with HF is necessary.

Cardioselective Beta-Blocker Treatment of Hypertension in Patients with Asthma: When Do Benefits Outweigh Risks?

Background. Benefits outweigh risks of cardioselective beta-blocker therapy in patients with nonsevere asthma and a history of heart failure or myocardial infarction (MI). This review summarizes the risks versus benefits of using cardioselective beta-blockers in the treatment of hypertension in patients with asthma. Methods. We searched the English literature from 1976 to 2011 via PubMed, EMBASE, and SCOPUS using the following search terms: “beta-blocker treatment of hypertension” AND “asthma”; “cardioselective beta-blockers” AND “asthma.” When pertinent articles were found, we assessed relevant articles cited in those papers. All studies related to cardioselective beta-blocker use in patients with asthma and hypertension were included. Results. Seven studies with patient populations ranging from 10 to 17 patients evaluated cardioselective beta-blockers in patients with asthma and hypertension. Atenolol and/or immediate-release metoprolol were evaluated in these studies. The duration of beta-blocker therapy in four studies was 1–8 weeks; two studies were single dose and one investigation lasted 8 months. Metoprolol and atenolol were generally well tolerated except at higher doses such as metoprolol >100 mg daily. Conclusion. In the absence of concomitant cardiovascular disease, routine use of beta-blockers for the treatment of hypertension in patients with asthma should be avoided

Chronic obstructive pulmonary disease: a slowly progressive cardiovascular disease masked by its pulmonary effects?

Chronic obstructive pulmonary disease: a slowly progressive cardiovascular disease masked by its pulmonary effects?

INCIDENCE OF DEPRESSION, CHRONIC FATIGUE AND SEXUAL DYSFUNCTION WITH BETA-BLOCKER USE: A META-ANALYSIS OF RANDOMIZED CONTROL TRIALS

Reluctance to using beta blockers may derive from concerns about their association with depression, sexual dysfunction and chronic fatigue. We used MEDLINE, Cochrane and EMBASE (through June 2011) to conduct a comprehensive search for randomized clinical trials of beta blocker use in patients with

Reprinted Article “A Combination of Statins and Beta-blockers is Independently Associated with a Reduction in the Incidence of Perioperative Mortality and Nonfatal Myocardial Infarction in Patients Undergoing Abdominal Aortic Aneurysm Surgery”

Objective To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). Background Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. Methods We studied 570 patients (mean age 69 ±9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. Results Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p = 0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24,95% CI: 0.10-0.70; p = 0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. Conclusions A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.

Managing Beta-blockers in Acute Heart Failure: When to Start and When to Stop?

The role of beta-blockers in heart failure has been long debated. Data from chronic heart failure studies clearly indicate that beta-blockers save lives. However, data concerning use of beta-blockers in patients with acute heart failure are limited, and only recently have emerged to help guide therapy. In this review, we provide an overview of when to stop and when to start beta-blockers in patients with acute heart failure.