Perioperative Beta-blocker Use Research Articles

The impact of beta-blocker use on postoperative atrial fibrillation after aortic valve replacement.

BackgroundCurrent guidelines recommend perioperative use of beta-blocker (BB) in patients undergoing cardiac surgery to prevent postoperative atrial fibrillation (POAF). However, this recommendation is mainly based on studies those exclusively enrolled patients undergoing coronary artery bypass grafting. This study was conducted to evaluate the impact of perioperative BB use on the occurrence of POAF after aortic valve replacement (AVR).MethodsFrom January 2015 to June 2018, 296 patients (male: female = 163:133) who underwent AVR at our institution were retrospectively reviewed. Patients who underwent concomitant valve surgery other than AVR or patients with preoperative arrhythmia were excluded. Mean age at the operation was 67±12 years. All patients were continuously tele-monitored for the occurrence of AF until discharge. Occurrence of any short runs of AF during the hospital stay was treated as POAF. Early outcomes were evaluated and perioperative factors associated with POAF were analyzed using a multivariable logistic regression model.ResultsEarly mortality rate was 3.7% (11 of 296 patients). The POAF occurred in 154 patients (52.0%). Univariate analyses demonstrated that postoperative use of BB as well as age, type of prosthesis, history of stroke, body surface area, and chronic kidney disease were associated with the occurrence of POAF. The multivariable model showed that postoperative use of BB within 24 hours after AVR was a preventive factor of POAF (odds ratio, 0.354; 95% CI, 0.163 to 0.770; P=0.009).ConclusionsPostoperative use of BB within 24 hours after AVR rather than preoperative use might be effective in prevention of POAF.

Common medications and survival in women with ovarian cancer: A systematic review and meta-analysis

ObjectivesOvarian cancer is usually diagnosed at an advanced stage when five-year relative survival is <50%. Therefore, strategies to improve survival are required. Studies suggest associations between common chronic disease medications such as metformin, statins, beta-blockers, aspirin and non-aspirin non-steroidal anti-inflammatory drugs (NA-NSAIDs) and improved cancer survival. We aimed to review the evidence for a possible relation between these medications and survival among women with ovarian cancer. MethodsWe conducted four systematic reviews and evaluated the risk of bias in the included studies. Where possible, we calculated pooled hazard ratios (pHR) and 95% confidence intervals (CI), excluding studies considered to have the potential for immortal time bias (ITB) which, in practice, was the major source of bias. ResultsWe identified 36 studies evaluating one or more of the medications (metformin n = 8, statins n = 12, beta-blockers n = 11, aspirin and/or NA-NSAIDs n = 9). We rated 21 studies as ITB-free. The meta-analysis of the ITB-free studies suggested improved survival in statin users compared to non-users (pHR: 0.76, 95%CI: 0.68–0.85), but no overall survival benefit associated with use of metformin, beta-blockers, aspirin or NA-NSAIDs. The pooled result of two studies did, however, suggest a possible association between perioperative beta-blocker use and improved survival. Studies considered to have potential ITB were more likely to report survival benefits associated with these medications. ConclusionStatin use is associated with better ovarian cancer survival but further study, preferably a clinical trial, is required. There are insufficient data to draw conclusions regarding metformin, beta-blockers, aspirin and NA-NSAIDs.

Beta-blocker exposure for short-term outcomes following non-cardiac surgery: A meta-analysis of observational studies.

It remains uncertain whether there is a benefit to perioperative beta-blocker use on outcomes after non-cardiac surgery. This meta-analysis aims to update the evidence regarding the associations between beta-blocker exposure and patient major short-term outcomes following non-cardiac surgery. Pubmed, Embase, and the Cochrane Central Register from their inception to May 2019 were searched by two independent authors. Observational studies reporting associations between perioperative beta-blocker treatment and short-term outcomes including 30-day all-cause mortality (ACM), 30-day major adverse cardiovascular events (MACE) and 30-day stroke risk were selected for inclusion. Meta-analyses were carried out by using random effects models. Nineteen studies with a total of 1,711,766 participants were identified. Beta-blocker exposure was associated with reduced 30-day all-cause mortality (ACM) (RR 0.83, 95% CI 0.72 to 0.96). No evidence of publication bias was observed. Subgroup analyses revealed that significant 30-day survival benefits were observed in prospective, population-based studies, drug exposure period last till 1-2 months after surgery, patients having abdominal gastrointestinal surgery or having 3-4 cardiac risk factors. Beta-blocker exposure was associated with increased 30-day ACM among patients with no cardiac risk factors (RR 1.30, 95% CI 1.19 to 1.43). However, meta-analysis demonstrated a non-significant risk reduction in 30-day MACE (RR 1.03; 95% CI 0.85 to 1.25) or 30-day stroke risk (RR 0.86; 95% CI 0.44 to 1.68) with beta-blocker exposure. The results of the current meta-analysis indicate beta-blocker exposure may be a significant indicator for 30-day ACM, but not for 30-day MACE or 30-day stroke risk. The association between beta-blocker exposure and long-term outcomes deserves further investigation.

Cochrane Corner: Perioperative beta-blockers for preventing surgery-related mortality and morbidity

Randomized controlled trials have yielded conflicting results regarding the impact of beta-blockers on perioperative cardiovascular morbidity and mortality. This Cochrane systematic review assessed the impact of this intervention on mortality and cardiovascular events.Eighty-eight randomized controlled trials with 19 161 participants were included (53 trials on cardiac surgery and 35 trials on non-cardiac surgery).In cardiac surgery perioperative beta-blockers had a protective effect against supraventricular and ventricular arrhythmias but had no significant effect on mortality or on the occurrence of acute myocardial infarction (AMI), stroke, heart failure, hypotension or bradycardia. In non-cardiac surgery, beta-blockers had a protective effect against AMI and arrhythmias, but this was counterbalanced by an increased risk of death and stroke.In conclusion, perioperative use of beta-blockers appears overall to be beneficial in cardiac surgery. However, in non-cardiac surgery the substantial reduction in rhythm disturbances and AMI appears to be offset by an increase in mortality and stroke, and so the systematic use of beta-blockers in this setting is not recommended.

Effect of Beta Blockers on Mortality After Open Repair of Abdominal Aortic Aneurysm.

To assess the effect of perioperative beta blocker (BB) use on postoperative in-hospital mortality after open repair of abdominal aortic aneurysm (OAR). Postoperative mortality after OAR ranges from 3.0% to 4.5%. Insight about the effect of BBs on postoperative mortality after OAR is currently lacking. This is a retrospective study of patients undergoing OAR from 2009-Q3 to 2015-Q1 in the Premier Healthcare Database. The Premier Healthcare Database includes data representing 20% of all inpatient US discharges annually. Patients under 45 years, admitted after a trauma or who underwent multiple aortic repair procedures, were excluded. Multivariable logistic regression models were created to assess the relationship between perioperative BB use and postoperative in-hospital mortality. Of 6515 patients admitted for OAR, 5423 (83.2%) received perioperative BBs. Patients who received BBs were more likely to develop major adverse events compared with those who did not (45.6% vs 35.2%; P < 0.001); however, failure to rescue was lower among BB users (7.6% vs 19.5%; P < 0.001). In a multivariable logistic regression model, BB use was associated with 57% [odds ratio 0.43, 95% confidence interval (CI) 0.31-0.56, P = 0.001) and 81% (odds ratio 0.19, 95% CI 0.11-0.31, P < 0.001) lower odds of mortality among patients without and with a history of coronary artery disease, respectively. The predicted mortality (95% CI) for patients who did not receive BBs, or received low, intermediate, or high-intensity BBs was 11.6% (8.0%-15.2%), 5.4% (4.4%-6.5%), 2.5% (1.9%-3.0%), and 3.3% (2.3%-4.3%), respectively. In-hospital use of BBs was associated with a significant reduction in postoperative mortality after OAR. This is the first study to demonstrate a dose-response relationship between BBs and postoperative mortality after OAR.

Association between perioperative beta blocker use and cancer survival following surgical resection

BackgroundRecent studies have demonstrated an association between beta-blocker exposure and improved survival in multiple cancer types. We sought to investigate the effects of beta-blockers at the time of index surgery for breast, lung, and colorectal cancer. Materials and methodsUsing linked data from a provincial cancer registry, we conducted a retrospective matched cohort study comparing disease-specific and overall survival between patients over age 64 exposed and not exposed to beta-blockers before and after index surgical resection for breast, lung and colorectal cancer between April 1st, 2002 and December 31st, 2010. A high-dimensional propensity score was used to match patients and Cox proportional hazard models were used to estimate relative risks of the outcomes. Results30,020 patients were included in the final matched cohorts. Mean follow up time for breast, lung, and colorectal cancer was 57.6 ± 30.5, 43.1 ± 28.7, and 53.4 ± 31.0 months, respectively. The adjusted hazard ratio for disease-specific mortality for patients exposed to beta-blockers was 1.03 (0.83–1.29) for breast, 1.05 (0.92–1.20) for lung, and 1.10 (0.96–1.25) for the colorectal cancer cohort. ConclusionsIn this large population-based study, no association between perioperative beta-blocker exposure and improved cancer-specific survival for breast, lung, or colorectal cancer was demonstrated.

Effect of Beta-Blockers on Perioperative Outcomes in Vascular and Endovascular Surgery: A Systematic Review and Meta-Analysis

Abstract Background To investigate the role of perioperative beta-blocker use in vascular and endovascular surgery. Methods We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. The review protocol was registered with International Prospective Register of Systematic Reviews (registration number:CRD42016038111). We searched electronic databases to identify all randomized controlled trials and observational studies investigating outcomes of patients undergoing vascular and endovascular surgery with or without perioperative beta blockade. We used the Cochrane tool and the Newcastle-Ottawa scale to assess the risk of bias of trials and observational studies, respectively. Random-effects models were applied to calculate pooled outcome data. Results We identified three randomized trials, five retrospective cohort studies, and three prospective cohort studies, enrolling a total of 32,602 patients. Our analyses indicated that perioperative use of beta-blockers did not reduce the risk of all-cause mortality [odds ratio (OR) 1.10, 95% confidence interval (CI) 0.59-2.04, P = 0.77], cardiac mortality (OR 2.62, 95% CI 0.86-8.05, P = 0.09), myocardial infarction (OR 0.89, 95% CI 0.59-1.35, P = 0.58), unstable angina (OR 1.34, 95% CI 0.41- 4.38, P = 0.63), stroke (OR 2.45, 95% CI 0.89-6.75, P = 0.08), arrhythmias (OR 0.76, 95% CI 0.41-1.43, P = 0.40), congestive heart failure (OR 1.12, 95% CI 0.77-1.63, P = 0.56), renal failure (OR 1.48, 95% CI 0.90-2.45, P = 0.13), composite cardiovascular events (OR 0.88, 95% CI 0.55-1.40, P = 0.58), rehospitalisation (OR 0.86, 95% CI 0.48-1.52, P = 0.60), and reoperation (OR 1.17, 95% CI 0.42-3.27, P = 0.77) in vascular surgery. Conclusions Beta-blockers do not improve perioperative outcomes in vascular and endovascular surgery.

Abstract 133: Outcomes Associated With Perioperative Amiodarone in Cardiac Surgery Patients Receiving Metoprolol

Background: Post-operative atrial fibrillation (POAF) after cardiac surgery occurs frequently and the guidelines make a Class I recommendation for peri-operative betablocker use and a Class IIa recommendation for amiodarone use in high risk patients to reduce length of stay and mortality. Our aim was to study the association between perioperative amiodarone use and clinical outcomes in patients already receiving metoprolol, in a real-world cohort. Methods: Using the PREMIER, Inc. data warehouse, we identified patients ≥18 years without atrial fibrillation at baseline, who underwent elective cardiac surgery during years 2013-2014. We included patients with conditions replicating prior randomized controlled studies. We then excluded all patients not receiving metoprolol. Perioperative amiodarone use was defined as administered on the day of surgery or prior to surgery within the same hospitalization. After propensity matching, we compared outcomes for patients receiving perioperative amiodarone + metoprolol vs. those who received only metoprolol. The primary outcome was POAF and secondary outcomes were in-hospital mortality, length of stay and 1 month readmission among survivors. Results: Among 4351 patients who underwent cardiac surgery and received metoprolol at 212 hospitals, 997 (23%) were treated with perioperative amiodarone. We matched 928 (94%) of perioperative amiodarone treated group based on the propensity score. Table 1 shows baseline characteristics and outcomes of interest in the propensity matched cohort. Median age was 66 years and 74% were male. The propensity matched cohort was well balanced on type of surgery and comorbidities and some imbalances remained in demographic variables. After adjusting for unbalanced factors in the matched cohort, perioperative amiodarone+ metoprolol was associated with reduction in POAF (ARR 5.1%; RR 0.81, 95% CI 0.69-0.95). There were no differences in in-hospital mortality, length of stay, 1 month readmission or cost of hospitalization. Conclusions: In this large cohort of propensity matched patients undergoing elective cardiac surgery, perioperative amiodarone use was associated with a modestly significant reduction in POAF rates, but there were no significant relationships with mortality, length of stay, 1 month readmission or costs.

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.

Editorial introductions

Editorial introductions

Relationship between beta-blockers and mortality in diabetic patients undergoing coronary artery bypass grafting

Background: Beta-blockers have an established role in the management of acute coronary syndromes. Whether beta-blockers also reduce adverse outcomes in the peri-operative setting, including in cardiac surgery, remains controversial. Purpose: We compared characteristics and outcomes of diabetic patients undergoing coronary artery bypass grafting (CABG) by whether they were on beta-blockers peri-operatively. Methods: All diabetic patients undergoing CABG during July 2010-June 2010 were included. Characteristics and outcomes including mortality and morbidities were collected and compared by baseline beta-blocker status. Results: Out of the 306 patients studied, 72.5% (222) were on a beta-blocker at the time of CABG. Not having beta-blocker treatment was associated with being female (41.8% vs 23.4%, P=0.005), intra-aortic balloon pump treatment (50.0% vs 25.4%, P=0.011), history of congestive heart failure (51.9% vs 25.1%, P=0.006), atrial fibrillation (52.4% vs 25.6%, P=0.02), impaired ejection fraction<40% (46.6% vs 23.0%, P=0.001), chronic respiratory disease (40.0% vs 24.7%, P=0.029) and dialysis (26.0% vs 52.9%, P=0.023). Beta-blocker use was associated with reduced operative mortality (0.5% vs 6.0%, P=0.007) and 1-year mortality (99.1% vs 88.1%, log-rank P=0.002), but not other post-operative complications including myocardial infarction or stroke. In multivariate analysis, beta-blocker use was independently associated with reduced 1-year mortality hazards ratio (95% confidence interval) 0.204 (0.063-0.654) but not operative mortality 0.227 (0.009-5.767) or morbidities. Conclusion: Peri-operative beta-blocker use was associated with reduced operative mortality and independently predicted improved 1-year mortality after CABG in diabetic patients. In the absence of contraindications, beta-blockers should be considered in all diabetic patients undergoing CABG.

Perioperative beta-blockers in noncardiac surgery: the evidence continues to evolve.

The effectiveness and safety of giving beta-blockers to patients undergoing noncardiac surgery remain controversial. The use of these drugs in this clinical scenario increased after the publication of two positive trials in the late 1990s and was encouraged by national organizations and clinical guidelines. However, when several subsequent studies failed to show a benefit, recommendations became more limited and use decreased. This paper reviews recent evidence for and against the perioperative use of beta-blockers.

Perioperative beta-blocker use and survival in lung cancer patients

Study ObjectiveTo assess the effect of perioperative beta blockers on recurrence and overall survival after non-small cell lung cancer surgery. DesignRetrospective study. SettingAcademic medical center. MeasurementsThe medical records of patients with stage 1, 2, and 3a non-small cell lung cancer were divided into three different groups: those patients who never received beta blockers perioperatively, those receiving nonselective beta blockers within 60 days of surgery, and those taking selective beta blockers within 60 days of surgery.Recurrence-free survival and overall survival were the main clinical endpoints. Univariate log-rank tests and multivariate Cox proportional hazards models were used to assess the effects of selective beta blockers, nonselective beta blockers, or no beta blockers on recurrence-free survival and overall survival. Main ResultsThe analysis included records of 435 patients. Univariate analyses showed that the use of both selective and nonselective beta blockers was associated with decreased recurrence-free survival (P = 0.014) and overall survival (P = 0.009). However, these findings were not sustained after adjusting for possible confounding variables in the multivariate analysis. The hazard ratios for recurrence-free survival (selective beta blockers vs no beta blocker use were: 1.304; 95% confidence intervals [CI] 0.973 - 1.747; P = 0.075; for nonselective beta blockers vs no beta blockers: 0.989; 95% CI 0.639 - 1.532; P = 0.962. The hazard ratios for overall survival were: selective beta blocker use vs no beta blockers: 1.335; 95% CI 0.966 - 1.846; P = 0.080; nonselective beta blocker use vs no beta blocker use: 1.108; 95% CI 0.678 - 1.812; P = 0.682. ConclusionAdministration of beta blockers during the perioperative period did not improve recurrence-free or overall survival in patients undergoing resection of non-small cell lung cancer.

International RCT-based guidelines for use of preoperative stress testing and perioperative beta-blockers and statins in non-cardiac surgery

BackgroundCardiologists frequently advise on perioperative care for non-cardiac surgery and require guidance based on randomised controlled trials that are not discredited by misconduct or misreporting. Regional political bodies currently do not provide this. We therefore examined the credible randomised controlled trial (RCT) evidence on key cardiac perioperative questions which currently have 14 recommendations. MethodsThree aspects of perioperative measures were considered: perioperative statins, preoperative stress-testing and perioperative beta-blockade. One author searched PubMed for RCTs considering these topics. All authors independently assessed the RCTs and then collaboratively composed guidelines. ResultsPerioperative statin therapy has been examined by three RCTs, DECREASE III and IV, which are discredited and a third containing serious inconsistencies undermining its validity.Preoperative stress testing has been examined by two RCTs: one discredited trial, DECREASE II, and a second which found no benefit.Perioperative beta-blockade has been examined by eleven RCTs, two of which are discredited. The nine remaining trials together suggest that perioperative beta-blockade increases mortality. ConclusionsWhen the non-credible RCTs are omitted, the evidence base on these three subjects is much smaller than previously believed: 14 recommendations can be replaced by 3.Current guideline arrangements collectively paralyse the numerous signatories from making urgent amendments after initial publication, even when important new information comes to light. Clinicians simply have to wait for the routine five-year expiry.We present a concise scientifically based guideline and commit to updating it responsibly.

Perioperative Beta-blocker and Statin use in Patients with Coronary Artery Disease Undergoing Orthotopic Liver Transplantation

Background: In patients that undergo Orthotopic Liver Transplantation (OLT), the presence of Coronary Artery Disease (CAD) is associated with worse short- and long-term outcomes. With reported 3-year mortality rates up to 50%, recent efforts have focused on ways to reduce perioperative cardiovascular risk in this population. While continuation of Beta-Blocker (BB) and statin therapy has been shown to benefit patients with known CAD undergoing intermediate or high-risk noncardiac surgery, it is unknown whether these therapies benefit patients with CAD undergoing OLT. Methods: We retrospectively identified 45 patients that underwent OLT between 2002 and 2010 with known CAD. Records were reviewed and patterns of BB (uninterrupted therapy, interrupted therapy no therapy, at hospital discharge) and statin (preoperative, at hospital discharge) use were categorized as indicated. Chi-square, Fisher's exact test, and ANOVA were employed to compare patterns of use with Length of Stay (LOS), as well as the incidence of death, Myocardial Infarction (MI), and composite death and Myocardial Infarction (MI) at both 30 days and 12 months post-OLT. Results: Thirty-three patients (73%) were on a BB at admission, and of these 20 (61%) had BB therapy withheld for > 48 hours. Twenty-seven (60%) patients were discharged on a BB. Eight patients out of 45 (18%) were on statin therapy chronically and had the drug continued till the time of OLT. Following transplantation, 1 patient (2%) was discharged on a statin. Overall there were 5 (11%) in-hospital MI in the cohort. Of these, none occurred in patients given continuous BB therapy, while 4 occurred in patients that had BB therapy withdrawn (p = 0.118) and 1 in a patient never administered BB. On univariate analysis, mean LOS differed with respect to BB use and was longer in those that had interrupted (20.3 ± 13.9 days) compared with uninterrupted BB therapy (11.5 ± 7.1; p = 0.020). Composite 1-year mortality and MI was 22% and did not differ with regard to BB or statin prescription at the time of discharge. Conclusions: In patients with CAD undergoing OLT there is a high rate of perioperative BB withdrawal. In addition, few patients are on statin therapy at the time of OLT, and most are not administered a statin postoperatively. BB withdrawal in this population was associated with a non-significant increase in 30-day MI and a significant increase in LOS. This observation, from the largest CAD-OLT cohort yet reported, calls for identifying reasons for BB withdrawal and provides support for increased vigilance with respect to BB provision in this population.

Associations between perioperative beta-blocker use and surgical outcomes

Associations between perioperative beta-blocker use and surgical outcomes

Whatʼs New in Adult Reconstructive Knee Surgery

The purpose of this review is to summarize studies on various topics in adult knee reconstruction that were published during the year 2010. The keywords “knee” and “arthroplasty” and “prospective” and “randomized” were used to perform a search of the National Library of Medicine’s PubMed database; the search was limited to studies that were published in The Journal of Bone and Joint Surgery (American Volume) or The Journal of Arthroplasty in 2010. The resulting seventeen studies are included in this review of adult reconstruction of the knee and are included in the complete bibliography at the end of the manuscript. In addition, other studies from 2010 were chosen for their specific relevance to the topics being discussed. Continuing research into the epidemiology and economics of adult hip and knee arthroplasty has improved our understanding of costs, processes of care, and outcomes. Data related to these topics are ever important in a time when standards and mandates of care are being generated by various administrative bodies. As health care protocols and recommended processes of care are generated, there is a clear need to validate decisions that affect entire populations of patients. Bozic et al.1 used the Perspective database to identify 182,146 patients managed with primary hip and knee arthroplasty in order to assess the independent effects of surgeon volume, hospital volume, and process standardization on short-term outcomes. The authors used adherence to antibiotic prophylaxis, the appropriate use of perioperative beta-blockers, and venous thromboembolism prophylaxis as a proxy for care that was provided with process standardization. As expected, both surgeon volume and hospital volume were associated with significant improvements in short-term outcomes, including reduced complication rates, reduced rates of reoperations and readmissions, reduced mortality, and reduced length of hospital stay. In addition, the authors found that process standardization was independently responsible …

Colchicine for the Prevention of Postoperative Atrial Fibrillation

Colchicine for the Prevention of Postoperative Atrial Fibrillation

Myocardial ischemia-reperfusion and cardioprotection: a study with microdialysis in a porcine model

The studies in this thesis are based on questions raised in the clinical setting. Perioperative myocardial ischemia occurs more often than recognized. This may lead to myocardial infarction, increased morbidity, mortality, and health care costs. In the first study, myocardial metabolism was investigated before, during, and after 30 min of regional coronary artery occlusion, utilizing the microdialysis technique, concomitantly with the monitoring of global circulation and local coronary artery flow in an open chest pig model. Myocardial interstitial metabolites demonstrated characteristic, significant, and reproducible changes as decreased glucose, increased glycerol, and increased lactate/pyruvate ratio during ischemia, normalizing after reperfusion. Of special interest was found that myocardial glycerol concentrations remained high initially at reperfusion, raising the hypothesis of this release corresponding to reperfusion injury. This model was used for the next two studies. In cardiac surgery, episodes of myocardial ischemia or decreased myocardial performance are highly expected to occur. Patients with poor cardiac function will have a double benefit of an inotropic drug with anti-ischemic properties. Levosimendan may have this potential. In the second study, it was demonstrated that an infusion of levosimendan started before the coronary artery occlusion, as compared to start during the ischemia, reduced the effect of ischemia on the myocardial metabolism, improved, and preserved cardiac performance during this period. In recent years, concerns with the use of perioperative beta-blockers have been debated. Beta-blockers may inhibit the pharmacological preconditioning elicited by volatile anaesthetics. In the third study, it was demonstrated that levosimendan, in the presence of beta-blockade, was still able to induce a cardioprotective effect on the myocardial ischemic metabolism. During cold cardioplegic storage, or in the future during preservation of donor hearts by perfusion, monitoring of the donor heart before transplantation may be of benefit. We hypothesized, that myocardial microdialysate glycerol will reflect progressive damage. As the first step in pursuing this, in the fourth study, the course of myocardial metabolites was investigated during ten hours of cold cardioplegic storage. An accelerating myocardial glycerol accumulation was demonstrated during storage, after an initial stable period, probably reflecting the acceptable storage time. (Less)

Other important applications for beta-blockers in high-risk patients.

Beta-blockers suppress the adverse effects of chronic activation of the sympathetic nervous system-which plays an important role in the progression of cardiovascular disease- and the drugs are also recommended as primary therapy in other diverse medical conditions that present treatment problems. For many patients with atrial fibrillation, a common condition that poses a high risk of stroke, heart rate control with beta-blockers is increasingly seen as a critical therapeutic component. Similarly, perioperative beta-blocker use provides clinical benefits in patients undergoing noncardiac surgery who are at risk of cardiac events. In migraine therapy, beta-blockers are well established as effective agents for prophylaxis, and beta-blockers may reduce levels of C-reactive protein, a sensitive marker of inflammation in cardiovascular disease. Reviewing the role of beta-blockers in several ancillary conditions should help illuminate various aspects of the complex progression of cardiovascular disease and clarify the drugs' various therapeutic benefits.