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Abstract
Accurately identifying persons with addiction is critically important for effectively targeting treatment and harm reduction interventions. Misdiagnosis of addictive disorders can lead to a cascade of negative outcomes, including stigma, discontinuation of needed medications, undue scrutiny of both patients and physicians, and even criminal consequences. A recent study raises significant concerns about the accuracy of diagnosis code data, likely rooted in confusingly-worded International Classification of Diseases (ICD)-9 and ICD-10 codes and a general misunderstanding of the difference between addiction and physiologic dependence. It is hardly surprising that physicians frequently mislabel patients when the ICD terms used to code for addiction are themselves misleading. ICD codes have not been updated to reflect current understanding of addiction, unlike those in the DSM-5. To explore this issue further, this commentary briefly discusses new information regarding coding data inaccuracies, how coding inaccuracies can lead to misdiagnosis, and the dangers of conflating "addiction" with "dependence." The commentary concludes with a call for the ICD to update their codes to reflect current understanding of addiction.Key messagesIt is not surprising that physicians frequently conflate patients with "addiction" and "dependence" when the ICD terms used to code for addiction are themselves misleading.ICD codes have not been updated to reflect what we know about the nature of addiction, unlike those in the DSM-5.This commentary calls for the ICD to update their codes to reflect current understanding of addiction.
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Affiliation(s)
- Maia Szalavitz
- Department of Mental Health Law & Policy, University of South Florida, Tampa, FL, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Khary K. Rigg
- Department of Mental Health Law & Policy, University of South Florida, Tampa, FL, USA
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Safi S, Sethi NJ, Korang SK, Nielsen EE, Feinberg J, Gluud C, Jakobsen JC. Beta-blockers in patients without heart failure after myocardial infarction. Cochrane Database Syst Rev 2021; 11:CD012565. [PMID: 34739733 PMCID: PMC8570410 DOI: 10.1002/14651858.cd012565.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cardiovascular disease is the number one cause of death globally. According to the World Health Organization (WHO), 7.4 million people died from ischaemic heart disease in 2012, constituting 15% of all deaths. Beta-blockers are recommended and are often used in patients with heart failure after acute myocardial infarction. However, it is currently unclear whether beta-blockers should be used in patients without heart failure after acute myocardial infarction. Previous meta-analyses on the topic have shown conflicting results. No previous systematic review using Cochrane methods has assessed the effects of beta-blockers in patients without heart failure after acute myocardial infarction. OBJECTIVES To assess the benefits and harms of beta-blockers compared with placebo or no treatment in patients without heart failure and with left ventricular ejection fraction (LVEF) greater than 40% in the non-acute phase after myocardial infarction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index - Expanded, BIOSIS Citation Index, the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, European Medicines Agency, Food and Drug Administration, Turning Research Into Practice, Google Scholar, and SciSearch from their inception to February 2021. SELECTION CRITERIA We included all randomised clinical trials assessing effects of beta-blockers versus control (placebo or no treatment) in patients without heart failure after myocardial infarction, irrespective of publication type and status, date, and language. We excluded trials randomising participants with diagnosed heart failure at the time of randomisation. DATA COLLECTION AND ANALYSIS We followed our published protocol, with a few changes made, and methodological recommendations provided by Cochrane and Jakobsen and colleagues. Two review authors independently extracted data. Our primary outcomes were all-cause mortality, serious adverse events, and major cardiovascular events (composite of cardiovascular mortality and non-fatal myocardial reinfarction). Our secondary outcomes were quality of life, angina, cardiovascular mortality, and myocardial infarction during follow-up. We assessed all outcomes at maximum follow-up. We systematically assessed risks of bias using seven bias domains and we assessed the certainty of evidence using the GRADE approach. MAIN RESULTS We included 25 trials randomising a total of 22,423 participants (mean age 56.9 years). All trials and outcomes were at high risk of bias. In all, 24 of 25 trials included a mixed group of participants with ST-elevation myocardial infarction and non-ST myocardial infarction, and no trials provided separate results for each type of infarction. One trial included participants with only ST-elevation myocardial infarction. All trials except one included participants younger than 75 years of age. Methods used to exclude heart failure were various and were likely insufficient. A total of 21 trials used placebo, and four trials used no intervention, as the comparator. All patients received usual care; 24 of 25 trials were from the pre-reperfusion era (published from 1974 to 1999), and only one trial was from the reperfusion era (published in 2018). The certainty of evidence was moderate to low for all outcomes. Our meta-analyses show that beta-blockers compared with placebo or no intervention probably reduce the risks of all-cause mortality (risk ratio (RR) 0.81, 97.5% confidence interval (CI) 0.73 to 0.90; I² = 15%; 22,085 participants, 21 trials; moderate-certainty evidence) and myocardial reinfarction (RR 0.76, 98% CI 0.69 to 0.88; I² = 0%; 19,606 participants, 19 trials; moderate-certainty evidence). Our meta-analyses show that beta-blockers compared with placebo or no intervention may reduce the risks of major cardiovascular events (RR 0.72, 97.5% CI 0.69 to 0.84; 14,994 participants, 15 trials; low-certainty evidence) and cardiovascular mortality (RR 0.73, 98% CI 0.68 to 0.85; I² = 47%; 21,763 participants, 19 trials; low-certainty evidence). Hence, evidence seems to suggest that beta-blockers versus placebo or no treatment may result in a minimum reduction of 10% in RR for risks of all-cause mortality, major cardiovascular events, cardiovascular mortality, and myocardial infarction. However, beta-blockers compared with placebo or no intervention may not affect the risk of angina (RR 1.04, 98% CI 0.93 to 1.13; I² = 0%; 7115 participants, 5 trials; low-certainty evidence). No trials provided data on serious adverse events according to good clinical practice from the International Committee for Harmonization of Technical Requirements for Pharmaceuticals for Human Use (ICH-GCP), nor on quality of life. AUTHORS' CONCLUSIONS Beta-blockers probably reduce the risks of all-cause mortality and myocardial reinfarction in patients younger than 75 years of age without heart failure following acute myocardial infarction. Beta-blockers may further reduce the risks of major cardiovascular events and cardiovascular mortality compared with placebo or no intervention in patients younger than 75 years of age without heart failure following acute myocardial infarction. These effects could, however, be driven by patients with unrecognised heart failure. The effects of beta-blockers on serious adverse events, angina, and quality of life are unclear due to sparse data or no data at all. All trials and outcomes were at high risk of bias, and incomplete outcome data bias alone could account for the effect seen when major cardiovascular events, angina, and myocardial infarction are assessed. The evidence in this review is of moderate to low certainty, and the true result may depart substantially from the results presented here. Future trials should particularly focus on patients 75 years of age and older, and on assessment of serious adverse events according to ICH-GCP and quality of life. Newer randomised clinical trials at low risk of bias and at low risk of random errors are needed if the benefits and harms of beta-blockers in contemporary patients without heart failure following acute myocardial infarction are to be assessed properly. Such trials ought to be designed according to the SPIRIT statement and reported according to the CONSORT statement.
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Affiliation(s)
- Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Naqash J Sethi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Eik Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Yang X, Hui L, Long H, Zou L. Distinct outcomes of labetalol exposed infants: case reports and systematic review. J Matern Fetal Neonatal Med 2021; 34:2012-2018. [PMID: 31510808 DOI: 10.1080/14767058.2019.1651270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 07/04/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The adverse effects of long-term maternal exposure of labetalol on neonates have been recognized clinically. But there are few systematic studies on their clinical demonstrations and potential mechanisms. METHODS A death case of an infant with long-term maternal labetalol exposure was reported and compared with two case reports from the literature. A systematic literature review was carried out followed by a retrospective analysis on neonatal labetalol withdrawal effects. RESULTS It was discovered that labetalol withdrawal effects initially cause various degrees of hypotension, hypoglycemia, and bradycardia among exposed neonates. Some life-threatening cases can also occur within 1 week after birth. Long-term maternal exposure of labetalol, preterm infants with birth asphyxia, acidosis, hypoalbuminemia, and cardiac defects are their primary features. Possible mechanisms were concluded as labetalol-induced effects on the vascular and sympathetic nervous system as well as tissue oxygen extraction. CONCLUSIONS Neonatal labetalol withdrawal effects include early-onset and late-onset demonstrations, the latter can be life-threatening. A possible mechanism is multiple factors induced imbalance of sympathetic homeostasis increases neonatal vulnerability to common stresses. Long-term exposed preterm infants complicated with asphyxia, acidosis, hypoalbuminemia and cardiac defects, should be provided with intense care during the first week after birth. Further work is necessary to enrich this hypothesis.
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Affiliation(s)
- Xiying Yang
- Children Medical Center, General Hospital of the People's Liberation Army, Beijing, China
| | - Liyuan Hui
- Department of Neonatal Pediatrics, People' Third Hospital of Xingtai City, Xingtai, China
| | - Hui Long
- Children Medical Center, General Hospital of the People's Liberation Army, Beijing, China
| | - Liping Zou
- Children Medical Center, General Hospital of the People's Liberation Army, Beijing, China
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Glaess SS, Attridge RL, Christina Gutierrez G. Clonidine as a strategy for discontinuing dexmedetomidine sedation in critically ill patients: A narrative review. Am J Health Syst Pharm 2020; 77:515-522. [PMID: 32086509 DOI: 10.1093/ajhp/zxaa013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE To review the efficacy and safety of transitioning from dexmedetomidine to clonidine to facilitate weaning of patients from sedation with dexmedetomidine. There is a paucity of data describing dexmedetomidine withdrawal syndrome (DWS) as well as clonidine's place in therapy for DWS. This review will describe and analyze current literature to provide clinical recommendations. SUMMARY A MEDLINE literature search was performed to identify original research articles describing DWS and/or transitioning from dexmedetomidine to clonidine for the purpose of weaning patients from sedation with dexmedetomidine. Four case reports describing DWS, 3 case reports describing the use of clonidine to treat DWS, and 3 observational studies describing the use of clonidine to facilitate dexmedetomidine weaning were identified. The incidence of and risk factors for DWS are unknown; factors including patient age and dexmedetomidine infusion rate, loading dose, and discontinuation strategy have inconsistent associations with DWS. All cases of DWS have been associated with infusion durations greater than 72 hours. While there are limited data describing clonidine use for the treatment of dexmedetomidine withdrawal, clonidine appears to be beneficial for dexmedetomidine weaning and its use for that purpose has been well described. Clonidine dosages that have been assessed for discontinuing dexmedetomidine vary from 0.1 to 0.3 mg orally or enterally every 6 to 8 hours; one study assessed use of transdermal clonidine (100 µg/24 h patch). Patients with extensive cardiac comorbidities may be more susceptible to adverse effects of clonidine, which may limit the drug's use for DWS intervention. CONCLUSION Despite limited supportive data, clonidine provides a promising option for sedation management in adult ICU patients, with successful transitions from dexmedetomidine reported within 24 hours after clonidine initiation.
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Affiliation(s)
- Shelley S Glaess
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, and UCHealth Memorial Hospital, Colorado Springs, CO
| | - Rebecca L Attridge
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, and UT Health San Antonio, San Antonio, TX
| | - G Christina Gutierrez
- UT Health San Antonio, San Antonio, TX, and University Health System, San Antonio, TX
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Tantisattamo E, Molnar MZ, Ho BT, Reddy UG, Dafoe DC, Ichii H, Ferrey AJ, Hanna RM, Kalantar-Zadeh K, Amin A. Approach and Management of Hypertension After Kidney Transplantation. Front Med (Lausanne) 2020; 7:229. [PMID: 32613001 PMCID: PMC7310511 DOI: 10.3389/fmed.2020.00229] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/04/2020] [Indexed: 12/14/2022] Open
Abstract
Hypertension is one of the most common cardiovascular co-morbidities after successful kidney transplantation. It commonly occurs in patients with other metabolic diseases, such as diabetes mellitus, hyperlipidemia, and obesity. The pathogenesis of post-transplant hypertension is complex and is a result of the interplay between immunological and non-immunological factors. Post-transplant hypertension can be divided into immediate, early, and late post-transplant periods. This classification can help clinicians determine the etiology and provide the appropriate management for these complex patients. Volume overload from intravenous fluid administration is common during the immediate post-transplant period and commonly contributes to hypertension seen early after transplantation. Immunosuppressive medications and donor kidneys are associated with post-transplant hypertension occurring at any time point after transplantation. Transplant renal artery stenosis (TRAS) and obstructive sleep apnea (OSA) are recognized but common and treatable causes of resistant hypertension post-transplantation. During late post-transplant period, chronic renal allograft dysfunction becomes an additional cause of hypertension. As these patients develop more substantial chronic kidney disease affecting their allografts, fibroblast growth factor 23 (FGF23) increases and is associated with increased cardiovascular and all-cause mortality in kidney transplant recipients. The exact relationship between increased FGF23 and post-transplant hypertension remains poorly understood. Blood pressure (BP) targets and management involve both non-pharmacologic and pharmacologic treatment and should be individualized. Until strong evidence in the kidney transplant population exists, a BP of <130/80 mmHg is a reasonable target. Similar to complete renal denervation in non-transplant patients, bilateral native nephrectomy is another treatment option for resistant post-transplant hypertension. Native renal denervation offers promising outcomes for controlling resistant hypertension with no significant procedure-related complications. This review addresses the epidemiology, pathogenesis, and specific etiologies of post-transplant hypertension including TRAS, calcineurin inhibitor effects, OSA, and failed native kidney. The cardiovascular and survival outcomes related to post-transplant hypertension and the utility of 24-h blood pressure monitoring will be briefly discussed. Antihypertensive medications and their mechanism of actions relevant to kidney transplantation will be highlighted. A summary of guidelines from different professional societies for BP targets and antihypertensive medications as well as non-pharmacological interventions, including bilateral native nephrectomy and native renal denervation, will be reviewed.
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Affiliation(s)
- Ekamol Tantisattamo
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States.,Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States.,Methodist University Hospital Transplant Institute, Memphis, TN, United States.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Bing T Ho
- Division of Nephrology and Hypertension, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Uttam G Reddy
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Donald C Dafoe
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Hirohito Ichii
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Antoney J Ferrey
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Alpesh Amin
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA, United States
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Illnesses Encountered During Medical Volunteering in Takeo Province, Cambodia. ACTA ACUST UNITED AC 2020; 56:medicina56010030. [PMID: 31936867 PMCID: PMC7023312 DOI: 10.3390/medicina56010030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 11/23/2022]
Abstract
Background and Objectives: Medical volunteering seeks to meet the clinical needs of underserved areas, but has been criticized for difficulties in addressing local health issues and resultant lack of sustainability. Our team has visited rural Cambodia annually since 2012. This study reports the illnesses encountered during the recent mission and share our experiences to improve the efficiency of medical volunteering. Materials and Methods: Infrastructure, such as public electricity or water, was unavailable, hence most medical care and records were hand-performed. We categorized (1) primary diagnoses (chief complaints) by duration of symptoms, and (2) primary and secondary diagnoses (illnesses that were not related to the chief complaint) by severity of illness since patients commonly reported multiple symptoms. Blood pressure and anthropometric values were also checked and analyzed. Results: We encountered 317 adult and 141 pediatric patients. Among adults, 61.3% had persistent chronic (>6 month) symptoms of their chief complaints. The commonest diagnoses of chronic symptoms were musculoarthritis (31.5%) and gastroesophageal reflux disease and/or gastritis (21.7%). Hypertension and/or cardiac problems were relatively common among males (13.6%). The most common diagnosis among the severest cases (specialized or intensive care recommended) was cardiac problems (14.8%), often with abnormalities in sonography or electrocardiogram. For children, the overwhelming majority of diagnoses were related to acute symptoms and low severity, and approximately half were cases of the common cold. Commonly prescribed drugs were antacids or mucosal protectors (31.3%), Non-steroidal anti-inflammatory drugs (NSAIDs) or other painkillers (27.6%), and antiparasites (17.7%) in adults, and NSAIDs (44.7%) and antiparasites (23.2%) in children. Among adults, 32.7% were diagnosed with hypertension, and body mass index (p = 0.003) and age (p < 0.001) were both correlated with hypertension and its grade. Conclusions: Our study offers practical help to volunteer health workers planning to visit Southeast Asia.
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Safi S, Sethi NJ, Nielsen EE, Feinberg J, Gluud C, Jakobsen JC. Beta-blockers for suspected or diagnosed acute myocardial infarction. Cochrane Database Syst Rev 2019; 12:CD012484. [PMID: 31845756 PMCID: PMC6915833 DOI: 10.1002/14651858.cd012484.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cardiovascular disease is the number one cause of death globally. According to the World Health Organization, 7.4 million people died from ischaemic heart diseases in 2012, constituting 15% of all deaths. Acute myocardial infarction is caused by blockage of the blood supplied to the heart muscle. Beta-blockers are often used in patients with acute myocardial infarction. Previous meta-analyses on the topic have shown conflicting results ranging from harms, neutral effects, to benefits. No previous systematic review using Cochrane methodology has assessed the effects of beta-blockers for acute myocardial infarction. OBJECTIVES To assess the benefits and harms of beta-blockers compared with placebo or no intervention in people with suspected or diagnosed acute myocardial infarction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded and BIOSIS Citation Index in June 2019. We also searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, Turning Research into Practice, Google Scholar, SciSearch, and the reference lists of included trials and previous reviews in August 2019. SELECTION CRITERIA We included all randomised clinical trials assessing the effects of beta-blockers versus placebo or no intervention in people with suspected or diagnosed acute myocardial infarction. Trials were included irrespective of trial design, setting, blinding, publication status, publication year, language, and reporting of our outcomes. DATA COLLECTION AND ANALYSIS We followed the Cochrane methodological recommendations. Four review authors independently extracted data. Our primary outcomes were all-cause mortality, serious adverse events according to the International Conference on Harmonization - Good Clinical Practice (ICH-GCP), and major adverse cardiovascular events (composite of cardiovascular mortality and non-fatal myocardial infarction during follow-up). Our secondary outcomes were quality of life, angina, cardiovascular mortality, and myocardial infarction during follow-up. Our primary time point of interest was less than three months after randomisation. We also assessed the outcomes at maximum follow-up beyond three months. Due to risk of multiplicity, we calculated a 97.5% confidence interval (CI) for the primary outcomes and a 98% CI for the secondary outcomes. We assessed the risks of systematic errors through seven bias domains in accordance to the instructions given in the Cochrane Handbook. The quality of the body of evidence was assessed by GRADE. MAIN RESULTS We included 63 trials randomising a total of 85,550 participants (mean age 57.4 years). Only one trial was at low risk of bias. The remaining trials were at high risk of bias. The quality of the evidence according to GRADE ranged from very low to high. Fifty-six trials commenced beta-blockers during the acute phase of acute myocardial infarction and seven trials during the subacute phase. At our primary time point 'less than three months follow-up', meta-analysis showed that beta-blockers versus placebo or no intervention probably reduce the risk of a reinfarction during follow-up (risk ratio (RR) 0.82, 98% confidence interval (CI) 0.73 to 0.91; 67,562 participants; 18 trials; moderate-quality evidence) with an absolute risk reduction of 0.5% and a number needed to treat for an additional beneficial outcome (NNTB) of 196 participants. However, we found little or no effect of beta-blockers when assessing all-cause mortality (RR 0.94, 97.5% CI 0.90 to 1.00; 80,452 participants; 46 trials/47 comparisons; high-quality evidence) with an absolute risk reduction of 0.4% and cardiovascular mortality (RR 0.99, 95% CI 0.91 to 1.08; 45,852 participants; 1 trial; moderate-quality evidence) with an absolute risk reduction of 0.4%. Regarding angina, it is uncertain whether beta-blockers have a beneficial or harmful effect (RR 0.70, 98% CI 0.25 to 1.84; 98 participants; 3 trials; very low-quality evidence) with an absolute risk reduction of 7.1%. None of the trials specifically assessed nor reported serious adverse events according to ICH-GCP. Only two trials specifically assessed major adverse cardiovascular events, however, no major adverse cardiovascular events occurred in either trial. At maximum follow-up beyond three months, meta-analyses showed that beta-blockers versus placebo or no intervention probably reduce the risk of all-cause mortality (RR 0.93, 97.5% CI 0.86 to 0.99; 25,210 participants; 21 trials/22 comparisons; moderate-quality evidence) with an absolute risk reduction of 1.1% and a NNTB of 91 participants, and cardiovascular mortality (RR 0.90, 98% CI 0.83 to 0.98; 22,457 participants; 14 trials/15 comparisons; moderate-quality evidence) with an absolute risk reduction of 1.2% and a NNTB of 83 participants. However, it is uncertain whether beta-blockers have a beneficial or harmful effect when assessing major adverse cardiovascular events (RR 0.81, 97.5% CI 0.40 to 1.66; 475 participants; 4 trials; very low-quality evidence) with an absolute risk reduction of 1.7%; reinfarction (RR 0.89, 98% CI 0.75 to 1.08; 6825 participants; 14 trials; low-quality evidence) with an absolute risk reduction of 0.9%; and angina (RR 0.64, 98% CI 0.18 to 2.0; 844 participants; 2 trials; very low-quality evidence). None of the trials specifically assessed nor reported serious adverse events according to ICH-GCP. None of the trials assessed quality of life. We identified two ongoing randomised clinical trials investigating the effect of early administration of beta-blockers after percutaneous coronary intervention or thrombolysis to patients with an acute myocardial infarction and one ongoing trial investigating the effect of long-term beta-blocker therapy. AUTHORS' CONCLUSIONS Our present review indicates that beta-blockers for suspected or diagnosed acute myocardial infarction probably reduce the short-term risk of a reinfarction and the long-term risk of all-cause mortality and cardiovascular mortality. Nevertheless, it is most likely that beta-blockers have little or no effect on the short-term risk of all-cause mortality and cardiovascular mortality. Regarding all remaining outcomes (serious adverse events according to ICH-GCP, major adverse cardiovascular events (composite of cardiovascular mortality and non-fatal myocardial infarction during follow-up), the long-term risk of a reinfarction during follow-up, quality of life, and angina), further information is needed to confirm or reject the clinical effects of beta-blockers on these outcomes for people with or suspected of acute myocardial infarction.
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Affiliation(s)
- Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Naqash J Sethi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
- Cardiology SectionDepartment of Internal MedicineSmedelundsgade 60HolbækDanmarkDenmark4300
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Christian Gluud
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
- University of Southern DenmarkDepartment of Regional Health Research, the Faculty of Health SciencesHolbaekDenmark
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Beeftink MMA, van der Sande NGC, Bots ML, Doevendans PA, Blankestijn PJ, Visseren FLJ, Voskuil M, Spiering W. Safety of Temporary Discontinuation of Antihypertensive Medication in Patients With Difficult-to-Control Hypertension. Hypertension 2017; 69:927-932. [PMID: 28373591 DOI: 10.1161/hypertensionaha.116.08793] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 12/06/2016] [Accepted: 03/01/2017] [Indexed: 01/09/2023]
Abstract
Successful control of blood pressure relies on identification of secondary causes and contributing factors of hypertension. As antihypertensive medication can interfere with diagnostic investigations, temporary discontinuation of medication is advised. However, there are concerns about the safety of temporary discontinuation of antihypertensive medication in patients with difficult-to-control hypertension. We assessed the occurrence of adverse cardiovascular and cerebrovascular events potentially attributable to temporary discontinuation of antihypertensive medication between February 2010 and March 2016 (n=604) in our Analysis of Complicated Hypertension screening program. A reference group (n=604) was extracted from the SMART study (Second Manifestations of Arterial Disease) cohort (comprising a similar cohort at our hospital in whom medication was not stopped) and individually matched for blood pressure, age, sex, and history of cardiovascular disease. Discontinuation of medication was well tolerated; 62% reported no complaints, 24% had mild discomfort that could be left untreated, and 14% experienced complaints that required prescription of antihypertensive escape medication. Three major adverse events were observed in the Analysis of Complicated Hypertension group between discontinuation of medication and 30 days after restart of medication (event rate=31.2 events per 1000 patient-year). In the reference cohort, 5 cardiovascular events were observed during a similar follow-up period (event rate=51.2 events per 1000 patient-year). In conclusion, discontinuation of antihypertensive medication for the diagnostic evaluation of hypertension does not increase the acute risk of cardiovascular events when performed in a well-controlled setting in specialized hospitals with appropriate protocols for monitoring safety.
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Affiliation(s)
- Martine M A Beeftink
- From the Department of Cardiology (M.M.A.B., P.A.D., M.V.), Department of Vascular Medicine (N.G.C.v.d.S., F.L.J.V., W.S.), Julius Center for Health Sciences and Primary Care (M.L.B.), Department of Nephrology and Hypertension (N.G.C.v.d.S., P.J.B.), University Medical Center Utrecht, The Netherlands
| | - Nicolette G C van der Sande
- From the Department of Cardiology (M.M.A.B., P.A.D., M.V.), Department of Vascular Medicine (N.G.C.v.d.S., F.L.J.V., W.S.), Julius Center for Health Sciences and Primary Care (M.L.B.), Department of Nephrology and Hypertension (N.G.C.v.d.S., P.J.B.), University Medical Center Utrecht, The Netherlands
| | - Michiel L Bots
- From the Department of Cardiology (M.M.A.B., P.A.D., M.V.), Department of Vascular Medicine (N.G.C.v.d.S., F.L.J.V., W.S.), Julius Center for Health Sciences and Primary Care (M.L.B.), Department of Nephrology and Hypertension (N.G.C.v.d.S., P.J.B.), University Medical Center Utrecht, The Netherlands
| | - Pieter A Doevendans
- From the Department of Cardiology (M.M.A.B., P.A.D., M.V.), Department of Vascular Medicine (N.G.C.v.d.S., F.L.J.V., W.S.), Julius Center for Health Sciences and Primary Care (M.L.B.), Department of Nephrology and Hypertension (N.G.C.v.d.S., P.J.B.), University Medical Center Utrecht, The Netherlands
| | - Peter J Blankestijn
- From the Department of Cardiology (M.M.A.B., P.A.D., M.V.), Department of Vascular Medicine (N.G.C.v.d.S., F.L.J.V., W.S.), Julius Center for Health Sciences and Primary Care (M.L.B.), Department of Nephrology and Hypertension (N.G.C.v.d.S., P.J.B.), University Medical Center Utrecht, The Netherlands
| | - Frank L J Visseren
- From the Department of Cardiology (M.M.A.B., P.A.D., M.V.), Department of Vascular Medicine (N.G.C.v.d.S., F.L.J.V., W.S.), Julius Center for Health Sciences and Primary Care (M.L.B.), Department of Nephrology and Hypertension (N.G.C.v.d.S., P.J.B.), University Medical Center Utrecht, The Netherlands
| | - Michiel Voskuil
- From the Department of Cardiology (M.M.A.B., P.A.D., M.V.), Department of Vascular Medicine (N.G.C.v.d.S., F.L.J.V., W.S.), Julius Center for Health Sciences and Primary Care (M.L.B.), Department of Nephrology and Hypertension (N.G.C.v.d.S., P.J.B.), University Medical Center Utrecht, The Netherlands
| | - Wilko Spiering
- From the Department of Cardiology (M.M.A.B., P.A.D., M.V.), Department of Vascular Medicine (N.G.C.v.d.S., F.L.J.V., W.S.), Julius Center for Health Sciences and Primary Care (M.L.B.), Department of Nephrology and Hypertension (N.G.C.v.d.S., P.J.B.), University Medical Center Utrecht, The Netherlands.
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Risk of acute myocardial infarction after discontinuation of antihypertensive agents: a case-control study. J Hum Hypertens 2017; 31:537-544. [PMID: 28332511 DOI: 10.1038/jhh.2017.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/17/2016] [Accepted: 01/03/2017] [Indexed: 11/08/2022]
Abstract
We performed a nested case-control study in a cohort of antihypertensive drug users to assess the association between discontinuation of different antihypertensive agents and the risk of acute myocardial infarction (AMI). Cases and controls were drawn from the Utrecht Cardiovascular Pharmacogenetics database. Patients who were hospitalised for their first AMI were considered cases and controls were not hospitalised for AMI. Antihypertensive users were defined as current users if the index date (date of AMI) fell within the prescribed duration or as discontinuers if this date fell outside the prescribed duration. According to the recency of discontinuation, discontinuers were divided into the following: recent discontinuers (⩽90 days), intermediate-term discontinuers (91-180 days) and long-term discontinuers (>180 days). We found that the risk of AMI was significantly increased in discontinuers, regardless of time since discontinuation, of beta-blockers (adjusted odds ratio (OR) 1.54; 95% confidence interval (CI; 1.25-1.91), P-value<0.0005), calcium channel blockers (CCBs; adjusted OR 2.25; 95% CI (1.53-3.30), P-value<0.0005) and diuretics (adjusted OR 1.76; 95% CI (1.24-2.48), P-value=0.002) compared to current users of these drugs. Moreover, the risk of AMI was significantly increased in long-term discontinuers (beta-blockers, CCBs, angiotensin-converting enzyme inhibitors and diuretics) and intermediate-term discontinuers (beta-blockers and CCBs) versus current users of these drugs. There was no difference in AMI risk between recent discontinuers of antihypertensive drugs versus current users of these drugs. In conclusion, discontinuation of antihypertensive drugs increases the risk of AMI after >90 days of discontinuation. This further underlines the importance of persistence to antihypertensive drug therapy to reduce the risk of AMI in patients with hypertension.
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11
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Nielsen EE, Feinberg J, Safi S, Sethi NJ, Gluud C, Jakobsen JC. Beta-blockers for non-acute treatment after myocardial infarction. Hippokratia 2017. [DOI: 10.1002/14651858.cd012565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Naqash J Sethi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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Nielsen EE, Feinberg J, Safi S, Sethi NJ, Gluud C, Jakobsen JC. Beta-blockers for suspected or diagnosed acute myocardial infarction. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Naqash J Sethi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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13
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VanderPluym J, Evans RW, Starling AJ. Long-Term Use and Safety of Migraine Preventive Medications. Headache 2016; 56:1335-43. [DOI: 10.1111/head.12891] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023]
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14
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Motivala AA, Parikh V, Roe M, Dai D, Abbott JD, Prasad A, Mukherjee D. 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. JACC Cardiovasc Interv 2016; 9:1639-48. [DOI: 10.1016/j.jcin.2016.05.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 04/29/2016] [Accepted: 05/19/2016] [Indexed: 02/01/2023]
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Kelly D, Hawdon G, Reeves J, Morris A, Cunningham M, Barrett J. Safety of intravenous metoprolol use in unmonitored wards: a single-centre observational study. Intern Med J 2016; 45:934-8. [PMID: 26109478 DOI: 10.1111/imj.12842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 06/10/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM This study aims to examine and quantify the risks associated with the use of intravenous metoprolol on unmonitored wards. METHOD This study was a retrospective single-centre observational study from 1 January 2009 to 31 December 2013. The study hospital was a 415-bed, private hospital in Melbourne, Victoria. The study population was all patients who received intravenous metoprolol on an unmonitored ward. The primary outcome measure was the rate of serious adverse events (SAE), defined as a complication of intravenous metoprolol resulting in transfer to a critical-care environment, a medical emergency team call or death. RESULTS Six hundred and nine patients received a total of 8260 doses of intravenous metoprolol. Seven cases were identified with a SAE deemed possibly related to beta-blocker use and there was one death. All SAE were hypotension, giving an overall rate of hypotension of 7/609 or 1.1% (95% confidence interval (CI), 0.5 to 2.4%) with a rate per dose delivered of 0.8/1000 doses (95% CI 0.3 to 1.7). The death occurred in a 94-year-old woman with abdominal sepsis. After case file review, consensus opinion deemed this to be unrelated to intravenous metoprolol. CONCLUSION The use of intravenous metoprolol on unmonitored wards appears to be safe. The complication rate was low, suggesting that this may be a sensible approach to the management of in-hospital populations at risk of beta-blocker withdrawal.
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Affiliation(s)
- D Kelly
- Intensive Care, Cabrini Hospital - Malvern, Melbourne, Victoria, Australia
| | - G Hawdon
- Intensive Care, Cabrini Hospital - Malvern, Melbourne, Victoria, Australia
| | - J Reeves
- Intensive Care, Cabrini Hospital - Malvern, Melbourne, Victoria, Australia
| | - A Morris
- Intensive Care, Cabrini Hospital - Malvern, Melbourne, Victoria, Australia
| | - M Cunningham
- Intensive Care, Cabrini Hospital - Malvern, Melbourne, Victoria, Australia
| | - J Barrett
- Intensive Care, Cabrini Hospital - Malvern, Melbourne, Victoria, Australia
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16
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Abstract
The concept of "perioperative hypertensive emergency" must be defined differently from that of ambulatory hypertensive emergency in view of its unique clinical considerations in an atypical setting. It should be noted that moderately high normal blood pressure (BP) values in the perioperative setting often trigger situations requiring immediate treatment in what would otherwise be a "BP-acceptable" non-surgical condition. Commonly recognized circumstances that may result in a perioperative hypertensive emergency include exacerbation of severe mitral insufficiency, hypertension resulting in acute decompensated heart failure, hypertension caused by acute catecholamine excess, rebound hypertension after withdrawal of antihypertensive medications, hypertension resulting in bleeding from vascular surgery suture lines, intracerebral hemorrhage, aortic dissection, hypertension associated with preeclampsia, and hypertension associated with autonomic dysreflexia. In addition, perioperative BP lability has been reported to increase the risk for stroke, acute kidney injury, and 30-day mortality in patients undergoing cardiac surgery.
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Affiliation(s)
- Solomon Aronson
- Department of Anesthesiology, Duke University School of Medicine, Box 3094, 102 Baker House, Durham, NC, 27710, USA,
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17
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Ge PS, Runyon BA. The changing role of beta-blocker therapy in patients with cirrhosis. J Hepatol 2014; 60:643-53. [PMID: 24076364 DOI: 10.1016/j.jhep.2013.09.016] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 09/13/2013] [Accepted: 09/17/2013] [Indexed: 12/11/2022]
Abstract
Cirrhosis is a leading cause of death in the United States and worldwide. Beta-blockers have been established in numerous studies as part of the cornerstone of the medical management of cirrhosis, particularly in the primary and secondary prevention of variceal hemorrhage. However, new evidence has cautioned the use of beta-blockers in patients with end-stage cirrhosis and refractory ascites. In this article, we review the beneficial effects of beta-blocker therapy, the potential harms of aggressive beta-blocker therapy, and provide suggestions regarding the appropriate use of this class of medications in patients with cirrhosis.
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Affiliation(s)
- Phillip S Ge
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Bruce A Runyon
- Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States.
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18
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Reidenberg MM. Drug discontinuation effects are part of the pharmacology of a drug. J Pharmacol Exp Ther 2011; 339:324-8. [PMID: 21849624 DOI: 10.1124/jpet.111.183285] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Most reviews of drug withdrawal effects focus on drugs of potential abuse such as opioids, benzodiazepines, etc. Abrupt discontinuation of many other drugs used in medicine cause withdrawal syndromes, some of which can be fatal. Discontinuation of a number of cardiovascular drugs can increase risk of cardiovascular events above that of people not taking these drugs. These include β-adrenergic receptor antagonists, aspirin, HMG-CoA reductase inhibitors (statins), and heparin. Rebound hypertension occurs after abrupt cessation of many antihypertensive drugs. The possibility of discontinuation syndromes has usually been neglected until adverse clinical events force them to be noticed. Attention to the possibility of drug discontinuation effects is an important part of drug safety evaluation.
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19
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Marik PE, Varon J. Perioperative hypertension: a review of current and emerging therapeutic agents. J Clin Anesth 2009; 21:220-9. [PMID: 19464619 DOI: 10.1016/j.jclinane.2008.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2007] [Revised: 09/07/2008] [Accepted: 09/19/2008] [Indexed: 01/05/2023]
Abstract
Perioperative hypertension is a common problem encountered by anesthesiologists, surgeons, internists, and intensivists. Surprisingly, no randomized, placebo-controlled studies exist that show that the treatment of perioperative hypertension reduces morbidity or mortality. Nevertheless, perioperative hypertension requires careful management. While sodium nitroprusside and nitroglycerin are commonly used to treat these conditions, these agents are less than ideal. Intravenous beta blockers and calcium channel blockers have particular appeal in this setting.
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Affiliation(s)
- Paul E Marik
- Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Affiliation(s)
- Adnan I. Qureshi
- From the Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis
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21
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Abstract
Perioperative hypertension is commonly encountered in patients that undergo surgery. While attempts have been made to standardize the method to characterize the intraoperative hemodynamics, these methods still vary widely. In addition, there is a lack of consensus concerning treatment thresholds and appropriate therapeutic targets, making absolute recommendations about treatment difficult. Nevertheless, perioperative hypertension requires careful management. When treatment is necessary, therapy should be individualized for the patient. This paper reviews the pharmacologic agents and strategies commonly used in the management of perioperative hypertension.
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Affiliation(s)
- Joseph Varon
- The University of Texas Health Science Center at Houston, TX, USA.
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22
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Karachalios GN, Charalabopoulos A, Papalimneou V, Kiortsis D, Dimicco P, Kostoula OK, Charalabopoulos K. Withdrawal syndrome following cessation of antihypertensive drug therapy. Int J Clin Pract 2005; 59:562-70. [PMID: 15857353 DOI: 10.1111/j.1368-5031.2005.00520.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In this study, a review of the available information concerning abrupt withdrawal of antihypertensive drug therapy is presented. Abrupt withdrawal of these drugs can produce a syndrome of sympathetic overactivity that includes nervousness, tachycardia, headache, agitation and nausea 36-72 h after cessation of the drug. A withdrawal syndrome may occur after discontinuation of almost all types of antihypertensive drugs, but mostly occurs with clonidine, beta-blockers, methyldopa and guanabenz. Less commonly can produce a rapid increase of the blood pressure to pre-treatment levels or above, or both and/or myocardial ischaemia. Although the exact incidence of the syndrome is not known, it appears to be rare, at least in patients receiving standard doses of the above antihypertensive drugs. The best treatment is prevention. In this study regarding the withdrawal syndrome that follows cessation of antihypertensive drugs therapy, a reference to the abrupt discontinuation of the main categories of antihypertensive drugs is also attempted.
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23
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Samson RH. Periprocedural hypertension: current concepts in management for the vascular surgeon. Vasc Endovascular Surg 2004; 38:361-6. [PMID: 15306955 DOI: 10.1177/153857440403800409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Periprocedural hypertension is a common finding in patients undergoing vascular surgery or endovascular procedures, and this may pose a risk for subsequent cardiovascular morbidity or mortality. Accordingly, the vascular surgeon who wishes to improve outcomes needs to be proficient not only in surgical technique but also in the medical management of the patient's associated conditions, especially hypertension. Vascular procedures need not be cancelled unless the blood pressure (BP) is more than 180 mm Hg systolic or 110 mm Hg diastolic, but attention should also be paid to evidence of end organ damage in making this decision. In most cases preoperative antihypertensive medications should be continued up till the procedure. Postoperative hypertension may require 1 of a number of intravenous medications, which are listed. Oral nifedipine should generally be avoided for fear of inducing an uncontrolled hypotensive response and cardiac ischemia.
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24
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References. Am J Kidney Dis 2004. [DOI: 10.1053/j.ajkd.2004.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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Simic J, Kishineff S, Goldberg R, Gifford W. Acute myocardial infarction as a complication of clonidine withdrawal. J Emerg Med 2003; 25:399-402. [PMID: 14654180 DOI: 10.1016/j.jemermed.2003.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Abrupt withdrawal from clonidine therapy is a well-known cause of hyperadrenergic symptoms, but reports of acute myocardial infarction are extremely rare. We present the case of an 86-year-old woman who developed severe hypertension and a myocardial infarction 36 h after terminating her therapy of clonidine, 0.4 mg/day. Symptoms quickly responded to the administration of labetolol and diazepam. Subsequent cardiac catheterization showed no evidence of coronary occlusion, suggesting that excessive myocardial oxygen demand was responsible for the infarction.
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Affiliation(s)
- John Simic
- Providence Saint Joseph Medical Center, Burbank, California 90033, USA
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26
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Abstract
Typically, old patients scheduled to undergo a surgical procedure take many medications for various disorders. The anaesthetist must consider the benefits and/or risks of continuation or withdrawal of such chronic medications. This chapter reviews these issues in respect of cardiovascular drugs (calcium channel blockers, beta adrenoreceptor antagonists, angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists) and of psychotropic and antiparkinson medications and insulin. Focus is put on the few scientific studies available and on the recommendations given by experts in the field.
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Affiliation(s)
- Thomas Bruessel
- Department of Anaesthesia and Pain Management, Canberra Clinical School, University of Sydney, The Canberra Hospital, Yamba Drive, Garran ACT 2605, Australia.
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27
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Senay EC, Adams EH, Geller A, Inciardi JA, Muñoz A, Schnoll SH, Woody GE, Cicero TJ. Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur. Drug Alcohol Depend 2003; 69:233-41. [PMID: 12633909 DOI: 10.1016/s0376-8716(02)00321-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 1994, the Drug Abuse Advisory Committee (DAAC) of the Food and Drug Administration (FDA) concluded that Ultram (tramadol hydrochloride) could be marketed as an analgesic drug without scheduling under the Controlled Substances Act based upon extensive pre-clinical, clinical and European epidemiological data. However, to guard against unexpectedly high levels of abuse in the United States, the DAAC recommended that an independent steering committee (ISC) be appointed to proactively monitor abuse/dependence. In the event that high rates of abuse were found, this ISC was given the authority to immediately recommend to the FDA that Ultram be scheduled. In the course of the surveillance project, the ISC received reports of withdrawal following abrupt discontinuation of Ultram and in some instances, following dose reductions. In most cases, the withdrawal symptoms consisted of classical opioid withdrawal, but in some cases were accompanied by withdrawal symptoms not normally observed in opiate withdrawal, such as hallucinations, paranoia, extreme anxiety, panic attacks, confusion and unusual sensory experiences such as numbness and tingling in one or more extremities. Withdrawal symptoms of either type were one of the more prevalent adverse events associated with chronic Ultram use, comprising nearly 40% of all adverse events reported with Ultram. Most of these consisted of typical opiate withdrawal symptoms, but 1 in 8 cases presented as atypical. These results indicate that physicians and other healthcare professionals need to be aware of the potential of Ultram to induce withdrawal of the classical opioid type, and that atypical withdrawal may also occur.
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Affiliation(s)
- Edward C Senay
- Pritzker School of Medicine, University of Chicago, Chicago, IL 60637, USA
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28
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Abstract
Although infrequent, perioperative cardiac complications are a source of major morbidity and mortality. As the population ages, the prevalence of cardiovascular disease is increasing. For physicians who refer patients for surgery as well as for clinicians directly involved in perioperative medical care, an understanding of perioperative cardiac complications, reduction of such complications, and treatment of complications is essential. This article summarizes the approach to perioperative hypertension, hypotension, myocardial ischemia, myocardial infarction, and congestive heart failure.
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Affiliation(s)
- H H Weitz
- Department of Medicine, Jefferson Medical College, Jefferson Heart Institute of Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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29
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Prichard BN, Graham BR. I1 imidazoline agonists. General clinical pharmacology of imidazoline receptors: implications for the treatment of the elderly. Drugs Aging 2000; 17:133-59. [PMID: 10984201 DOI: 10.2165/00002512-200017020-00005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
In recent years evidence has accumulated for the existence of central imidazoline (I1) receptors that influence blood pressure. While there is some controversy, it has been suggested that clonidine exerts its blood pressure-lowering effect mainly by activation of imidazoline I1 receptors in the rostral ventrolateral medulla, while its sedative effect is mediated by activation of central alpha2-receptors. Moxonidine and rilmenidine are 2 imidazoline compounds with 30-fold greater specificity for I1 receptors than for alpha2-receptors. In comparison, clonidine displays a 4-fold specificity for I1 receptors compared with alpha2 receptors. Moxonidine and rilmenidine lower blood pressure by reducing peripheral resistance. They reduce circulating catecholamine levels and moxonidine reportedly reduces sympathetic nerve activity in patients with hypertension. Moxonidine and rilmenidine modestly reduce elevated blood glucose levels and moxonidine has been reported to reduce insulin resistance in hypertensive patients with raised insulin resistance. Small reductions in plasma levels of total cholesterol, low density lipoprotein-cholesterol and triglycerides have been reported with rilmenidine. Both moxonidine and rilmenidine are well absorbed after oral administration and are eliminated unchanged by the kidneys. The elimination half-life (t(1/2)) of rilmenidine and moxonidine is 8 and 2 hours, respectively, but trough/peak plasma concentration ratios indicate that moxonidine can be administered once daily, suggesting possible CNS retention. As would be expected, t(1/2) values are increased in patients with reduced renal function, and in elderly individuals. Both drugs have been compared with established antihypertensive drugs from all the major groups. Studies, almost all of which were of a double-blind, parallel-group design, indicate that blood pressure control with moxonidine or rilmenidine is similar to that with established drugs, i.e. alpha-blocking drugs, calcium antagonists, ACE inhibitors, beta-blocking drugs and diuretic agents. There have been few studies conducted solely in elderly patients. However, evidence clearly suggests that the antihypertensive effect of the imidazoline compounds is not reduced in elderly patients. The overall adverse effect profile of moxonidine and rilmenidine compares reasonably with established agents. In accord with the receptor-binding studies, drowsiness and dry mouth are observed less often with these drugs than with other centrally acting drugs, although the symptoms occur more often than with placebo. An overshoot of blood pressure was seen when treatment with clonidine, but not moxonidine, was abruptly discontinued in conscious, spontaneously hypertensive rats. Clinical evidence of withdrawal reaction with moxonidine or rilmenidine is scant but caution should be observed pending more formal studies.
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Affiliation(s)
- B N Prichard
- Centre for Clinical Pharmacology, University College London, England
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30
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Abstract
Internists are frequently asked to do preoperative consultations and to manage perioperative complications. Realistic goals are to identify patient factors that increase the risk of surgery, to quantify this risk in order to make decisions about the appropriateness of and timing of the surgery, to provide recommendations on how to minimize the risk, to identify and manage coexisting medical conditions and their associated medication requirements, to monitor the patient for perioperative problems, and to make recommendations to deal with these problems when they occur. With few exceptions, nonselective imaging and laboratory screening tests have repeatedly been shown to be of little value when the history and physical do not suggest a problem. The risk associated with the planned surgery can be estimated, with the most common serious complications being cardiac events. Updated versions of Goldman's risk indices are particularly helpful for this. Clinical variables are optimally combined with selective stress testing to discern which patients will benefit from preoperative revascularization. This has been studied best in the setting of vascular surgery. A critical guiding principle is that the value of revascularization must be judged in terms of long term gains rather than just immediate perioperative benefit. Other interventions include the selective use of beta blockers, adequate analgesia for all, control of hypertension, and appropriate volume management, especially in the settings of preexisting CHF or valvular disease. It must also be recognized that perioperative ischemia and CHF often present atypically. An approach that combines aspects of both the ACC/AHA and the ACP guidelines seems optimal. A variety of noncardiac issues must also be addressed. Postoperative pulmonary complications are common, especially with preexisting pulmonary disease, thoracic and upper abdominal surgery, and obesity. PFTs and ABGs are indicated in selected patients. Stopping smoking, incentive spirometry, and selective use of bronchodilators and antibiotics are helpful. Patients with rheumatologic diseases have specific concerns based on systemic manifestations of disease including anemia, thrombocytopenia, pulmonary fibrosis, pericarditis, and hypercoagulability; medication effects particularly from steroids and nonsteroidal anti-inflammatory drugs; and specific joint problems including contractures and atlantoaxial joint instability. Diabetes increases the risk of infection and cardiac complications. Prevention of ketoacidosis and glucose control are necessary and can be achieved through a variety of approaches, depending on whether the patient suffers from Type 1 or Type 2 diabetes. The threshold for transfusion has increased in recent years, as has the use of erythropoietin and autologous blood donation. There is no longer an absolute hemoglobin that requires transfusion, although most require transfusion for hemoglobins less than 8 mg/dL, especially in the setting of cardiac disease and bloody surgery. The elderly require surgery at an increased rate and often do not do as well as younger patients. The primary issues are, however, not their age but their increased frequency of underlying disease and diminished reserve. The latter makes them prone to postoperative delirium, sensitivity to medications, and cardiac and pulmonary problems. Despite the many diseases that patients often have and the stresses of surgery itself, modern anesthetic and surgical techniques allow almost all patients to undergo necessary procedures at acceptable risk. The internist plays a critical role in minimizing this risk even further.
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Affiliation(s)
- E Nierman
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA.
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31
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Oparil S, Dyke S, Harris F, Kief J, James D, Hester A, Fitzsimmons S. The efficacy and safety of valsartan compared with placebo in the treatment of patients with essential hypertension. Clin Ther 1996; 18:797-810. [PMID: 8930424 DOI: 10.1016/s0149-2918(96)80040-3] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A multicenter, randomized, placebo-controlled, double-masked, parallel-group study was performed to compare the efficacy and safety of valsartan 20, 80, 160, and 320 mg with placebo in the treatment of patients with essential hypertension. A total of 736 adults with uncomplicated essential hypertension stages 1 to 3 were randomized to receive placebo or valsartan 20, 80, 160, or 320 mg daily for 8 weeks. Assessments were made at baseline, after 4 and 8 weeks of treatment, and 2 to 3 days after stopping treatment. The primary efficacy variable was change from baseline in mean sitting diastolic blood pressure (MSDBP). Other variables included change from baseline in mean sitting systolic blood pressure (MSSBP) and responder rates (ie, MSDBP < 90 mm Hg or decrease of > or = 10 mm Hg from baseline). All doses of valsartan produced statistically significant reductions in both MSDBP and MSSBP at end point compared with placebo. A dose-response effect was seen, although the incremental reduction in blood pressure with doses of valsartan > 80 mg was relatively small. Statistically significant differences in responder rates at end point were seen for doses of valsartan of 80 mg and above compared with placebo, whereas the responder rates for valsartan 20 mg was not significantly different from that for placebo. Safety and tolerability variables included data on adverse experiences, rebound hypertension, and clinical laboratory evaluations. Tolerability was good, with headache being the most common complaint and occurring most frequently in placebo patients. The incidence of dizziness was similar among the placebo (5.4%) and valsartan 20-mg to 160-mg groups (2.1% to 3.4%); there was an increase in the incidence of dizziness in the 320-mg group (9.3%). No cases of symptomatic orthostatic hypotension occurred. Analysis of rebound showed that 11.6% of patients receiving placebo and 16.6% receiving valsartan had an increase in MSDBP to baseline levels or above 2 to 3 days after stopping treatment. No clinically significant adverse experiences were noted after stopping treatment. There were no clinically or statistically significant changes in laboratory values during treatment. Thus valsartan proved to be both effective and safe in reducing blood pressure in adults with essential hypertension. The optimal dose range is 80 to 160 mg, given once daily.
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Affiliation(s)
- S Oparil
- University of Alabama at Birmingham, Alabama, USA
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33
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Sato K, Kojima M, Dohi Y. Antihypertensive treatment in patients with a history of accelerated malignant hypertension, with special reference to clinical decision-making in changing treatment. Clin Exp Hypertens 1994; 16:303-15. [PMID: 8038756 DOI: 10.3109/10641969409072218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Conditions under which patients with hypertension controlled by combined therapy may be able to be switched to monotherapy were investigated. Eleven patients with benign phase accelerated malignant hypertension had their long-term combination antihypertensive treatment withdrawn for 1 day in an attempt to determine factors contributing to individual variability in the extent of BP increase. Patients were divided into two groups according to BP on day 1: patients with DBP above 130 mmHg formed group A, and those with DBP below 130 mmHg formed group B. Group A patients were not controlled by monotherapy with manidipine, even at the maximal dose of 60 mg/day, while group B patients were satisfactorily controlled by manidipine 20 mg/day. Group A patients had renal dysfunction whereas those in group B did not. Thus, renal dysfunction appears to be the most important single factor in predicting whether long-term combination therapy may be reduced in patients with a history of accelerated malignant hypertension.
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Affiliation(s)
- K Sato
- Second Department of Internal Medicine, Nagoya City University Medical School, Japan
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34
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Takata Y, Yoshizumi T, Ito Y, Hirota Y, Fujishima M. Doxazosin withdrawal and ambulatory blood pressure monitoring in normotensive subjects. Angiology 1994; 45:17-23. [PMID: 8285380 DOI: 10.1177/000331979404500103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The effect of doxazosin withdrawal on normotensive subjects was examined by ambulatory blood pressure monitoring (ABPM) during twenty-four hours. Eight normotensive volunteers were treated with doxazosin for four weeks. ABPM was done the day before withdrawal and on the second and seventh days after withdrawal. The average systolic and diastolic BP were not altered by doxazosin withdrawal either on day 2 or day 7, but pulse rate (PR) decreased on day 2 and day 7. Daytime PR decreased on day 2, but both daytime and nighttime PR decreased on day 7. On withdrawal of doxazosin, the plasma norepinephrine concentration decreased and the plasma renin activity tended to decrease. Neither overshooting hypertension nor cardiovascular event was related to doxazosin withdrawal was observed. It is concluded that, in normotensive subjects, discontinuation of doxazosin may result in bradycardia without hypotension or signs of withdrawal syndrome.
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Affiliation(s)
- Y Takata
- First Division of Internal Medicine, National Fukuoka Central Hospital, Japan
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35
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Abstract
Cardiovascular diseases are the leading causes of death in the United States, with hypertension being amongst the most prevalent of the cardiovascular risk factors. Improvement of hypertension management has, in consequence, received much attention. Extensive pre- and post-marketing experience with the transdermal formulation of clonidine marketed in the USA in the mid-1980s has now been accumulated. Transdermal clonidine is effective as monotherapy in mild-moderate hypertension, and in combination with diuretics, calcium antagonists and ACE inhibitors in more resistant cases. It controls blood pressure throughout the 24-h circadian cycle. It is effective and generally well-tolerated in adolescents, the elderly, blacks, diabetics, and subjects with chronic renal insufficiency. It has been used perioperatively and for suppression of adrenergic symptoms in subjects withdrawing from addicting substances. In comparison with oral clonidine, transdermal clonidine reduces the incidence and severity of such symptomatic side-effects as dry mouth, drowsiness, and sexual dysfunction. Minor skin reactions occur at the site of application of the transdermal patch with moderate frequency. Adherence to transdermal clonidine therapy is high, and patients commonly prefer it to oral therapy. Transdermal administration of clonidine is a useful therapeutic advance in the long-term management of hypertension.
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Affiliation(s)
- J F Burris
- Department of Medicine, Georgetown University Medical Center, Washington, DC
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Prisant LM, Carr AA, Hawkins DW. Treating hypertensive emergencies. Controlled reduction of blood pressure and protection of target organs. Postgrad Med 1993; 93:92-6, 101-4, 108-10. [PMID: 8433961 DOI: 10.1080/00325481.1993.11701601] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Diastolic blood pressure of 120 mm Hg or more is often cited as identifying a hypertensive crisis. However, the absolute level of blood pressure may not be as important as the rate of increase. One important feature that distinguishes hypertensive emergency from hypertensive "urgency" is the ongoing vascular damage that occurs with hypertensive emergency. When this is present, therapy should be initiated as soon as possible. The initial goal is to reduce mean arterial pressure about 15% to 25% within the first 48 hours. Overzealous or uncontrolled reduction in blood pressure may result in coma, stroke, myocardial infarction, acute renal failure, or death. Thus, a drug with titratable dosing (eg, intravenous nitroprusside sodium [Nipride, Nitropress]) is preferred in most situations. Patients with hypertensive urgency do not have evidence of vascular damage. Usually, they are asymptomatic, have no retinal lesions, and have a marked elevation in diastolic blood pressure. Hypertensive urgency does not require immediate normalization of blood pressure, but initiation of therapy and careful follow-up are critical.
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Affiliation(s)
- L M Prisant
- Section of Hypertension and Vascular Diseases, Medical College of Georgia, Augusta 30912-3150
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39
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Affiliation(s)
- M C Houston
- Medical Intensive Care Unit, Vanderbilt University Medical Center, Nashville, TN 37232
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40
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Bell PE, Hossack KF, Gabow PA, Durr JA, Johnson AM, Schrier RW. Hypertension in autosomal dominant polycystic kidney disease. Kidney Int 1988; 34:683-90. [PMID: 2974094 DOI: 10.1038/ki.1988.233] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) has been shown to be associated with a greater than 50 percent incidence of hypertension prior to deterioration in renal function as assessed by glomerular filtration rate. The present study provides evidence for increased cardiac pre-load, as assessed by plasma atrial natriuretic factor (ANF) and cardiac index, in hypertensive as compared to normotensive ADPKD. The hypertensive ADPKD patients exhibited an increased renal vascular resistance as compared to the normotensive patients in spite of comparable glomerular filtration rates. It is hypothesized that the renal involvement of hypertensive ADPKD patients causes an impaired renal response to the observed increase in cardiac index, and also may release a venoconstrictor (such as angiotensin) which contributes to the enhanced cardiac pre-load and thus the hypertension.
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Affiliation(s)
- P E Bell
- University of Colorado School of Medicine, Denver
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41
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Houston MC, Hodge R. Beta-adrenergic blocker withdrawal syndromes in hypertension and other cardiovascular diseases. Am Heart J 1988; 116:515-23. [PMID: 2899971 DOI: 10.1016/0002-8703(88)90627-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- M C Houston
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232
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42
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Abstract
Clonidine is a centrally active antihypertensive agent effective in the treatment of mild, moderate and severe hypertension, alone or in combination with other drugs. Use of oral clonidine has often been limited by side effects which include dry mouth and drowsiness. Transdermal clonidine was therefore developed as an alternative to oral therapy. Ideally, a drug administered at a constant rate into the systemic circulation should attain steady-state concentrations with less peak-to-trough fluctuation than that associated with intermittent oral dosing. In theory, transdermal administration should thus minimise the adverse effects associated with peak plasma drug concentration, while avoiding the potential for decreased efficacy associated with trough levels. Clonidine has been incorporated into a small, pliable adhesive cutaneous delivery device designed to provide therapeutically effective doses of drug at a constant rate for at least 7 days. The transdermal therapeutic system is a laminate consisting of an external film impermeable to moisture and to the drug, a thin layer of active drug dispersed within a highly drug-permeable matrix, a membrane with a controlled intrinsic permeability regulating the rate of delivery of drug to the skin, and an adhesive coating that attaches the system to the skin surface. The permeation of drug through the skin occurs primarily by diffusion. Application of the clonidine transdermal system to both normotensive and hypertensive subjects has consistently reduced systolic and diastolic blood pressures. Maximum reduction in blood pressure occurs 2 to 3 days after initial application, and is maintained for at least 7 days or until the system is removed. The rate at which clonidine is presented to the skin surface is controlled by the microporous membrane: this rate is the same for all strengths of transdermal clonidine, the amount of clonidine released being proportional to its surface area. Thus, the daily dose is regulated by the area of skin covered. Typically, steady-state plasma concentrations are reached on the fourth day after initial transdermal system application. The lack of dose dependency in half-life and renal clearance estimates emphasise that the transdermal absorption of clonidine is linear. The plasma clonidine concentration produced by a particular transdermal dose varies considerably between individuals as a result of interindividual variation in renal clearance. For this reason, it is recommended that dosages be titrated up from the smallest system (3.5 cm2) until the desired pharmacological effect has been obtained.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- D T Lowenthal
- Department of Geriatrics and Adult Development, Mt Sinai School of Medicine, New York
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43
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Johns DW, Peach MJ. Factors that contribute to resistant forms of hypertension. Pharmacological considerations. Hypertension 1988; 11:II88-95. [PMID: 3280499 DOI: 10.1161/01.hyp.11.3_pt_2.ii88] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Treatment failure may be caused by induction of compensatory mechanisms that compromise effectiveness of the antihypertensive regimen. Antihypertensive agents have been classified according to mechanism of action, and compensatory mechanisms usually evoked by each class of drugs have been reviewed. Host factors may be responsible for the inability to control blood pressure or may predict special sensitivity or contraindication to a particular class of antihypertensive agents. Recommendations have been made for modification of stepped-care regimens and selection of initial antihypertensive agents based on host factors. Experimental evidence suggests the ability to target antihypertensive therapy in a manner that will prevent or reverse specific end-organ damage. Clinical studies are needed to define the long-term benefit derived from aggressive target organ protection.
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Affiliation(s)
- D W Johns
- Department of Pharmacology, University of Virginia School of Medicine, Charlottesville 22908
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44
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Abstract
Antihypertensive drugs with pharmacological action due to sympatholytic activity have been second only to diuretics in their use and efficacy in normalizing blood pressure. Their pharmacological actions have resulted in the notable absence of chemical toxicity, but because of symptomatic side effects, their use has been limited relative to some of the newer antihypertensive agents. Most prominent among undesirable side effects are the central nervous system findings of sedation, altered thought process, depression, and orthostatic or exercise hypotension. Sexual problems, especially in men, are also prominent. Special toxicity is discussed with reference to methyldopa, clonidine, monoamine oxidase inhibitors, and metyrosine.
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Affiliation(s)
- K Engelman
- Hospital of the University of Pennsylvania, University of Pennsylvania Medical School, Philadelphia 19104
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45
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Galley P, Manciet G, Hessel JL, Michel JP. Antihypertensive efficacy and acceptability of rilmenidine in elderly hypertensive patients. Am J Cardiol 1988; 61:86D-90D. [PMID: 2894166 DOI: 10.1016/0002-9149(88)90472-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Elderly hypertensive patients (older than 70 years, with a diastolic blood pressure [BP] between 95 and 114 mm Hg) were entered into a study after a 2-week wash-out period and randomized to 2 parallel groups: rilmenidine (n = 28) and methyldopa (n = 30). The initial dose (rilmenidine, 1 mg once daily A.M. or methyldopa, 250 mg twice daily) was doubled (1 mg twice daily or 500 mg twice daily, respectively) on day 21 if supine diastolic BP remained greater than 90 mm Hg. After a 6-week treatment period (days 0 to 42, with weekly examinations), the effects of treatment withdrawal (day 42) were evaluated twice daily (days 43 to 45), with a final examination on day 49. Most of the 58 patients (70%) (aged 81.5 +/- 0.8 years) with a mean diastolic BP of 100.2 +/- 0.7 mm Hg remained treated with the initial dose in both groups. Efficacy in both groups was identical on day 42: decrease in systolic and diastolic BP of approximately 18 mm Hg, with 85% of patients having BP levels normalized (supine diastolic BP less than or equal to 90 mm Hg). Compared with the reference period, no increase in adverse effects was noted apart from a moderate dryness of mouth in 15% of patients in both groups; no orthostatic hypotension was observed.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P Galley
- Service de Médecine Interne, Gériatrie, Groupe Hospitalier Sud, Bordeaux, France
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46
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George CF, Robertson D. Clinical consequences of abrupt drug withdrawal. MEDICAL TOXICOLOGY AND ADVERSE DRUG EXPERIENCE 1987; 2:367-82. [PMID: 3312931 DOI: 10.1007/bf03259954] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Syndromes due to the abrupt withdrawal of drug treatment occur mainly with adrenal corticosteroids and agents with an action on either the cardiovascular system or central nervous system. The abrupt withdrawal of antihypertensive therapy typically results in symptoms of overactivity in the sympathetic nervous system. Clonidine and beta-adrenoceptor antagonists are clinically the most important of these agents, but numerous other drugs have been implicated. Overall, the problem is small when viewed in the context of the huge scale of prescribing of antihypertensive medicines. A more serious problem is the occurrence of crescendo angina following the abrupt withdrawal of beta-adrenoceptor antagonists. Although other factors may be involved, adaptive up-regulation of beta-adrenoceptor density is the most likely cause of crescendo angina, and renders the patient more susceptible to sympathetic nervous stimulation following withdrawal of treatment. Besides leading to a recrudescence of the disease being treated, the withdrawal of corticosteroids can cause a variety of syndromes. In particular, problems can arise as a result of treatment-induced suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Another steroid withdrawal syndrome of unknown aetiology, without significant abnormalities of the HPA axis occurring, has been described. Benign intracranial hypertension may rarely follow steroid withdrawal in children. The syndromes associated with withdrawal of drugs which have an action on the CNS are poorly understood. Withdrawal of neuroleptic drugs can be followed by symptoms that resemble those described following withdrawal of anticholinergic drugs, and those agents with the greatest muscarinic-receptor-blocking properties are those which are most frequently implicated. However, the less common withdrawal dyskinesias are thought to reflect up-regulation of dopaminergic receptors during long term treatment. Gastrointestinal symptoms predominate following the abrupt withdrawal of antidepressants but hypomania and an 'akathisia-like' syndrome have been reported. Barbiturates are no longer recommended as hypnotics because of severe effects of withdrawal and the existence of safer alternatives. Short acting barbiturates can be withdrawn by replacement with either phenobarbitone (phenobarbitol) or diazepam and subsequent gradual reduction in dose. The recognition of dependency on benzodiazepines has been slow because of the similarity of mild withdrawal symptoms to the original problem which led to treatment being offered.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- C F George
- Clinical Pharmacology Department, University of Southampton
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47
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48
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Abstract
Optimal care of the patient with heart disease undergoing noncardiac surgery requires that the members of the surgical team, including anesthesiologist, internist-cardiologist, and surgeon, be familiar with the cardiovascular response to surgery, preoperative cardiac risk stratification, and the unique pathogenesis of cardiac complications that may occur in the perioperative period. Preoperative evaluation and computation of cardiac risk, anesthetic considerations, along with perioperative care of the patient with ischemic heart disease, valvular heart disease, congestive heart failure, arrhythmias and conduction disorders, and hypertension is discussed.
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49
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Cubeddu LX, Hoffmann IS, Davila S, Escontrelas C, Morales C, Rios A. Effects of propranolol, clonidine and hydrochlorothiazide treatment and abrupt discontinuation on central and peripheral noradrenergic activity in essential hypertension. Life Sci 1986; 39:2463-74. [PMID: 3540504 DOI: 10.1016/0024-3205(86)90489-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This study was undertaken to investigate further the CNS actions of commonly employed antihypertensive drugs. Measurements of cerebrospinal fluid (CSF) and plasma catecholamines (CA) were made in an attempt to estimate the activity of central and peripheral noradrenergic neurons during treatment with or after abrupt discontinuation of treatment with clonidine (CLO), propranolol (PRO), hydrochlorothiazide (HCTZ) or placebo, in patients with essential hypertension. A randomized, parallel, placebo-controlled, single-blind design was employed. BP reductions equal to or greater than 10 mmHg were observed with CLO (0.36 +/- 0.07 mg daily), PRO (160 mg +/- 0 mg daily) or HCTZ (70 +/- 12 mg daily). CLO reduced plasma norepinephrine (NE) by 64% and PRO increased it by 25%. Neither HCTZ nor placebo modified plasma NE. Plasma renin activity (PRA) was reduced by PRO (51%, P less than 0.01) and CLO (35%, P less than 0.05). CSF-NE levels (pg/ml) were significantly lower in the CLO group (CLO: 175 +/- 23; PRO: 278 +/- 35; HCTZ: 255 +/- 34; placebo: 203 +/- 7).
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50
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Foulks CJ, Cushner HM. Sexual dysfunction in the male dialysis patient: pathogenesis, evaluation, and therapy. Am J Kidney Dis 1986; 8:211-22. [PMID: 3532769 DOI: 10.1016/s0272-6386(86)80029-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Impotence is a common problem in male dialysis patients. Although dialysis patients may appear to have more reasons to be depressed than nondialysis patients, depression has not been found to be correlated with erectile dysfunction in this group. Primary testicular failure is common in male dialysis patients as is hyperprolactinemia. These disorders may be the cause of impotence in some of these patients. An algorithm for the evaluation and treatment of impotence in the male dialysis patient is presented. Successful renal transplantation is associated with improvement in the testicular failure, in the hyperprolactinemia, and in the erectile dysfunction of the male patient with end-stage renal disease.
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