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Affiliation(s)
- J A Kastor
- Department of Medicine, University of Maryland School of Medicine, Baltimore
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Das G, Tschida V, Gray R, Dhurandhar R, Lester R, McGrew F, Askenazi J, Kaplan K, Emanuele M, Turlapaty P. Efficacy of esmolol in the treatment and transfer of patients with supraventricular tachyarrhythmias to alternate oral antiarrhythmic agents. J Clin Pharmacol 1988; 28:746-50. [PMID: 2905710 DOI: 10.1002/j.1552-4604.1988.tb03209.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The efficacy and safety of esmolol, a titratable intravenous beta-adrenergic blocking agent with a short elimination half-life (t 1/2 = 9.0 min) was evaluated in a multicenter open-label study for the treatment of supraventricular tachyarrhythmias (heart rate greater than 100 bpm). The study also investigated the feasibility of transferring patients from esmolol to alternate oral antiarrhythmic agents without loss of therapeutic response. Of the 113 patients studied, 95 (84%) achieved therapeutic response (reduction in heart rate of 15% or more or conversion to sinus rhythm). Most of these patients (93%) achieved the therapeutic response at esmolol doses of 200 micrograms/kg/min or lower. Transfer from esmolol to an oral antiarrhythmic agent(s) was studied in 76 patients. Alternate antiarrhythmic agents used in this study were digoxin (N = 25), propranolol (N = 21), verapamil (N = 10), metoprolol (N = 11), quinidine (N = 2), and a combination of two antiarrhythmic agents (N = 7). Sixty-seven (88%) patients were successfully transferred to oral antiarrhythmic agents without loss of the therapeutic response obtained with esmolol. The most frequent adverse effect observed during the study was hypotension, which resolved quickly (16 +/- 14 min) either by decreasing the dose or by discontinuation of esmolol infusion. This study supports previous observations concerning the safety and efficacy of esmolol in the treatment of supraventricular tachyarrhythmias. Furthermore, it demonstrates that the majority of patients successfully treated with esmolol can be safely and effectively transferred to oral therapy with alternate antiarrhythmic agents.
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Affiliation(s)
- G Das
- V.A. Medical Center, Fargo, North Dakota
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3
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Abstract
Beta-receptor-blocking agents are commonly used in the management of various cardiovascular diseases. Recently, esmolol, a pharmacokinetically novel cardioselective beta-receptor-blocking agent, has been introduced for use in the treatment of critically ill patients. It is devoid of intrinsic sympathomimetic activity and in doses used clinically, it has no direct depressant effect on the heart. Esmolol is an ester and is metabolized by choline-esterase to ASL 8123, an inactive molecule. Esmolol has an elimination half-life of nine minutes which accounts for its ultrashort duration of action. This unique pharmacokinetic property provides two advantages over other longer-acting beta-receptor-blocking agents. First, the magnitude of beta-receptor blockade can be titrated to a desired level. Second, if adverse effects are experienced, reducing the dosage or terminating the infusion results in rapid reversal of its pharmacological effects. Another ultrashort-acting, non-cardioselective beta-receptor blocking agent, flestolol is undergoing clinical evaluation. Esmolol has been approved for the management of supraventricular tachycardia. The clinical safety of these novel drugs will expand the use of beta-receptor-blocking agents in the management of cardiovascular diseases in critically ill patients.
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Affiliation(s)
- V S Murthy
- Department of Medicine, University of Wisconsin Medical School, Sinai Samaritan Medical Center, Milwaukee 53201-0342
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4
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Abstract
The ultra-short-acting beta-adrenergic blockers are parenteral agents that can be rapidly titrated in clinical situations where immediate beta-adrenergic blockade is warranted. The effects of those drugs rapidly dissipate after termination of treatment, providing an important safety feature. Esmolol, the prototype drug of this class, is approved for treatment of supraventricular tachyarrhythmias but also has potential use in treatment of patients with perioperative hypertension and acute myocardial ischemia.
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Affiliation(s)
- W H Frishman
- Albert Einstein College of Medicine, Bronx, New York
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Affiliation(s)
- J W Upward
- Clinical Pharmacology Group, University of Southampton, U.K
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Turlapaty P, Laddu A, Murthy VS, Singh B, Lee R. Esmolol: a titratable short-acting intravenous beta blocker for acute critical care settings. Am Heart J 1987; 114:866-85. [PMID: 2889341 DOI: 10.1016/0002-8703(87)90797-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Esmolol (Brevibloc) is an intravenous, short-acting, titratable, cardioselective beta blocker with a very rapid onset and offset of action (t1/2 = 9.2 minutes). Esmolol-induced beta blockade can be maintained as long as infusion is continued. It exhibits neither intrinsic sympathomimetic activity nor significant membrane-stabilizing activity. It is rapidly metabolized by an esterase in the erythrocyte cytosol to an inactive acid metabolite. Its hemodynamic and electrophysiologic effects are similar to those of other beta blockers. Unlike the effects of other beta blockers, however, the effects of esmolol dissipate rapidly to baseline within 30 minutes after its discontinuation. Evidence obtained from clinical studies indicates that esmolol is effective and safe in reducing the ventricular rate in patients with supraventricular tachyarrhythmias, and in reducing the heart rate in patients with acute myocardial infarction and/or unstable angina. Esmolol has also been shown to be effective and safe in attenuating the tachycardia and hypertension seen during the intraoperative period. Data from postoperative patients indicate that esmolol is ideal as sole-agent therapy for the treatment of moderate postoperative hypertension associated with a hyperdynamic state. The short duration of action and titratability of esmolol make it an ideal drug for use in patients in whom the clinical need for beta blockade is limited in duration, and it offers additional safety in patients in whom beta blockade is beneficial; however, it might be precluded because of coexisting contraindications. To date, experience with esmolol in over 1200 patients has been gathered, and the adverse effect profile is basically similar to that reported here.
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Affiliation(s)
- P Turlapaty
- Department of Clinical Research, Du Pont Critical Care, Waukegan, IL 60085
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Singh BN, Thoden WR, Wahl J. Acebutolol: a review of its pharmacology, pharmacokinetics, clinical uses, and adverse effects. Pharmacotherapy 1986; 6:45-63. [PMID: 3012486 DOI: 10.1002/j.1875-9114.1986.tb03451.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Acebutolol is a new hydrophilic, cardioselective beta-adrenergic-blocking agent that possesses partial agonist and membrane-stabilizing activities. In the treatment of mild to moderate essential hypertension, once-daily acebutolol as monotherapy provides effective control in a large majority of patients and produces a further reduction in blood pressure when used concomitantly with diuretics. Acebutolol is as effective as other beta-blocking agents, and in a large, double-blind, parallel study against propranolol was found to cause less reduction in heart rate, and fewer neurologic side effects and patient withdrawals due to adverse effects. Oral acebutolol is also effective in suppressing premature ventricular contractions, and in small numbers of patients generally beneficial results were obtained in supraventricular and ventricular arrhythmias with intravenous administration. These salutary effects are attributable to beta blockade. Controlled clinical trials documented the antianginal actions of oral acebutolol in chronic stable angina pectoris; its efficacy in this regard is comparable to that of other beta-blocking agents. The drug produces smaller decreases in heart rate and cardiac output and alterations in peripheral vascular hemodynamics than beta-blocking drugs without partial agonist activity, and because of its cardioselectivity, it may be used cautiously in patients with bronchospastic disease. Acebutolol has minimal metabolic effects and does not elevate levels of blood lipids during long-term therapy; high-density-lipoprotein cholesterol increased with acebutolol in a small number of patients.
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Crean PA, Williams DO. Effect of intravenous and oral acebutolol in patients with bundle branch block. Int J Cardiol 1986; 10:119-26. [PMID: 3943932 DOI: 10.1016/0167-5273(86)90219-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We studied the effect of intravenous (1 mg/kg) and oral (400 mg) acebutolol on atrioventricular conduction in 22 patients with idiopathic bundle branch block and 1 to 1 atrioventricular conduction. Seven patients had previously symptomatic complete heart block (Group 1) and 15 were asymptomatic with bundle branch block only (Group 2). Following intravenous acebutolol heart rate decreased 82 +/- 16 to 63 +/- 16/min (P less than 0.01), A-H interval lengthened 98 +/- 22 to 121 +/- 30 msec (P less than 0.005) and H-V time was prolonged 60 +/- 13 to 70 +/- 17 msec (P less than 0.02) in those with previous heart block. The corresponding changes in the patients with no previous block were 74 +/- 14 to 61 +/- 8/min (P less than 0.01), 90 +/- 17 to 109 +/- 22 msec (P less than 0.05) and 48 +/- 15 to 56 +/- 14 msec (P less than 0.01). There was no difference between the basal or induced changes between these two groups. After intravenous acebutolol infusion 2 of 6 patients with previous spontaneous heart block and none of those without previous heart block developed atrioventricular block distal to His. The induced block was temporary (less than 10 min) and corresponded to the time of peak plasma acebutolol levels. Temporary atrioventricular block followed oral acebutolol administration in 4/7 patients with previous spontaneous heart block and 0/14 in those without block. In patients with bundle branch block intravenous acebutolol prolonged H-V conduction times in 19/20 patients and intravenous and oral acebutolol induced A-V block in 4/7 patients with previous spontaneous block.(ABSTRACT TRUNCATED AT 250 WORDS)
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Chandraratna PA. Comparison of acebutolol with propranolol, quinidine, and placebo: results of three multicenter arrhythmia trials. Am Heart J 1985; 109:1198-204. [PMID: 3993535 DOI: 10.1016/0002-8703(85)90709-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acebutolol was compared to placebo, propranolol, and quinidine for the suppression of chronic ventricular arrhythmia in three double-blind, randomized crossover studies. Patients averaged greater than or equal to 10 to 30 premature ventricular contractions (PVCs) per hour in the baseline periods. Compared to baseline in all three studies, acebutolol significantly (p less than 0.002 to p less than 0.001) reduced mean total PVCs and complex PVCs. In all measurements, acebutolol was superior to placebo (p less than 0.02 to p less than 0.001) and comparable to propranolol and quinidine. During acebutolol treatment, 39% of the patients had reductions of greater than or equal to 75% in mean hourly PVC frequency compared to 23% during placebo treatment (p = 0.02). Similar numbers of patients had greater than or equal to 75% reductions during acebutolol treatment in comparison with propranolol and quinidine. Acebutolol was better tolerated than quinidine and produced an antiarrhythmic effect equivalent to that of propranolol, with a significantly (p less than 0.01) lesser decrease in resting heart rate. The antiarrhythmic activity of acebutolol, its ancillary pharmacologic properties, and its tolerance by a diverse group of patients make acebutolol a significant tool for the clinician in the management of chronic arrhythmia.
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Platia EV, Berdoff R, Stone G, Reid PR. Comparison of acebutolol and propranolol therapy for ventricular arrhythmias. J Clin Pharmacol 1985; 25:130-7. [PMID: 2580866 DOI: 10.1002/j.1552-4604.1985.tb02813.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The effects of acebutolol, a new investigational cardioselective beta blocker, and propranolol on ventricular arrhythmias were compared in 14 patients with more than 30 premature ventricular contractions (PVCs) per hour. Each patient served as their own control, receiving both drugs and placebo in random sequence and in double-blind fashion, with an intervening one-week, drug-free period. Each drug was given for a two-month period, the maximum acebutolol dosage reaching 600 mg tid and the maximum propranolol dosage 80 mg tid. Seventy-two-hour ambulatory electrocardiographic monitoring assessed arrhythmia frequency for each study period. Mean PVC counts did not significantly differ during the two control periods. Acebutolol decreased mean PVC count by 65% (P less than .02), with eight patients exhibiting a 70% or greater decrease. Only three patients exhibited a similar decline with propranolol. The incidence of PVCs was not significantly decreased by propranolol. Acebutolol reduced the number of couplets by 70% (P less than .04), whereas propranolol did not significantly affect couplets. At the dosage of 600 mg tid, acebutolol was well tolerated, effectively suppressed total PVCs and couplets, and appeared to be more effective than propranolol administered at 80 mg tid.
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Abengowe CU. A double-blind comparison of acebutolol (Sectral) and propranolol (Inderal) in the treatment of hypertension in black Nigerian patients. J Int Med Res 1985; 13:116-21. [PMID: 2860041 DOI: 10.1177/030006058501300207] [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: 01/03/2023] Open
Abstract
Acebutolol and propranolol were compared in forty-five Black African patients in a double-blind randomized trial carried out at Ahmadu Bello University Teaching Hospital in Kaduna, Nigeria. After a wash-out period of 6 weeks, including placebo administration for the last 4 of those weeks, twenty-seven patients were given acebutolol once daily and eighteen were given propranolol twice daily for 12 weeks, followed by a tapering-off period of 2 weeks, making a total of 14 weeks on active treatment. The two beta-receptor blocking drugs were effective in controlling hypertension with final daily doses ranging from 160 to 320 mg in the propranolol group and 400 to 800 mg in the acebutolol group. The supine systolic blood pressure responses with acebutolol were statistically significant and better than those elicited by propranolol. Acebutolol produced less (resting) bradycardia than did propranolol; this may be related to acebutolol's intrinsic sympathomimetic activity. The only unpleasant side-effects reported in this study were slight dizziness in two patients treated with propranolol and slight tiredness in one patient treated with acebutolol. No significant abnormal changes were noted in laboratory tests or chest X-rays. Electrocardiography detected supraventricular tachyarrythmia in five patients: this disappeared by the end of the study. Acebutolol was shown to be a safe, effective and reliable antihypertensive drug, at least comparable to and probably slightly better than, propranolol in the treatment of hypertension in Black Nigerians. It has the added advantage of a once-daily dose schedule.
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Lui HK, Lee G, Dhurandhar R, Hungate EJ, Laddu A, Dietrich P, Mason DT. Reduction of ventricular ectopic beats with oral acebutolol: a double-blind, randomized crossover study. Am Heart J 1983; 105:722-6. [PMID: 6846115 DOI: 10.1016/0002-8703(83)90231-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The antiarrhythmic efficacy of oral acebutolol, a new cardioselective beta-blocking agent, was assessed in a randomized double-blind, placebo-controlled study. Twenty-five patients with greater than or equal to 30 ventricular ectopic beats (VEB) per hour on three control ambulatory monitorings were studied. Mean VEB reduction from the control period was 35% with placebo and 45% and 50% with the use of acebutolol 200 mg and 400 mg, respectively. Eleven patients had greater than or equal to 70% reduction in VEB with acebutolol and nine of them had greater than or equal to 90 VEB reduction. Among these 11 patients, the mean VEB suppression was 51% after placebo but significantly higher following the two doses of acebutolol at 71% (p less than 0.05) and 86% (p less than 0.01). The mean reduction of paired VEB compared to placebo was 71% (p less than 0.05) and 75% (p less than 0.01) following 200 mg and 400 mg of acebutolol and only 49% after placebo. Complete suppression of paroxysmal ventricular tachycardia was also noted in five patients. Mean PR interval only increased slightly when patients took 400 mg of acebutolol, but there was no significant change in either the QRS or QTc intervals. A significant decrease in heart rate from that during control periods was noted after acebutolol. No significant adverse reactions were noted during the study. Acebutolol appears to be an effective and well-tolerated antiarrhythmic agent in the treatment of VEB and higher grades of ventricular ectopy.
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Santoso T, Nursyirwan EF, Trisnohadi HB, Manurung D, Rahman AM, Abdurahman N. Suppression of ventricular arrhythmia by acebutolol. Clin Cardiol 1983; 6:58-63. [PMID: 6831786 DOI: 10.1002/clc.4960060204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Kou HC, Yeh SJ, Lin FC, Hung JS, Wu D. Effects of acebutolol on paroxysmal atrioventricular reentrant tachycardia in patients with manifest or concealed accessory pathways. Chest 1983; 83:92-7. [PMID: 6848337 DOI: 10.1378/chest.83.1.92] [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: 01/22/2023] Open
Abstract
Electrophysiologic studies before and after administration of 50 mg of intravenous (IV) acebutolol were performed in 20 patients. Four of the 20 had persistent preexcitation, two had intermittent preexcitation, and 14 had a concealed retrogradely conducting accessory pathway (AP). Acebutolol depressed anterograde AP conduction with loss of preexcitation in one patient and increased the effective refractory period of AP in the remaining three; in most, it depressed anterograde normal pathway conduction. The longest atrial paced cycle length producing atrioventricular (AV) nodal block increased from 290 +/- 7 to 39 +/- 6 msec (mean +/- SEM) after acebutolol (p less than 0.01). Acebutolol had no significant effect on retrograde AP conduction. Sustained AV reentrant tachycardia was inducible in all 20 patients before acebutolol and in 19 after acebutolol. The cycle length of tachycardia increased from 323 +/- 8 to 352 +/- 8 msec after acebutolol (p less than 0.01), reflecting an increment of A-H interval from 148 +/- 8 to 174 +/- 9 msec (p less than 0.01). Electrophysiologic studies were reported after 800 mg of oral acebutolol given in four divided doses at six-hour intervals in eight patients. The results were comparable to those of IV acebutolol. Thus, acebutolol depresses AV nodal conduction and slows the rate of AV reentrant tachycardia, but is generally ineffective in inhibiting the induction of sustained tachycardia. It occasionally depresses anterograde AP conduction.
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De Soyza N, Shapiro W, Chandraratna PA, Aronow WS, Laddu AR, Thompson CH. Acebutolol therapy for ventricular arrhythmia. A randomized placebo-controlled double-blind multicenter study. Circulation 1982; 65:1129-33. [PMID: 7042111 DOI: 10.1161/01.cir.65.6.1129] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The safety and efficacy of acebutolol in suppressing ventricular ectopy was evaluated in 60 males (average 59 years) using 24-hour Holter recordings and a double-blind, randomized, crossover protocol. Acebutolol, 200 mg and 400 mg thrice daily, was compared with placebo. Only patients who had a mean of at least 30 ventricular premature complexes (VPCs) per hour on three 24-hour control Holter recordings were included. Analysis of Holter recordings revealed greater than 70% reduction in VPCs/hour from control levels during acebutolol therapy in over 50% of the 60 patients; dose-related reduction in the mean number of single and paired VPCs and ventricular tachycardia episodes (p less than 0.05) by acebutolol; and significant, asymptomatic reduction in resting heart rate and blood pressure. All side effects were transient. Acebutolol was discontinued because of side effects in one patient only.
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Abstract
The new and potent antiarrhythmic drugs herald an exciting era in the treatment of cardiac arrhythmias. Encainide, tocainide, and mexiletine are effective in treating acute and chronic ventricular arrhythmias. Verapamil promises to be the drug of choice for paroxysmal supraventricular tachycardia. Acetubolol provides the advantages of selective beta receptor blockade and has minimal influence on pulmonary function. Aprindine and amiodarone block conduction in accessory pathways and are very suitable for treating tachycardias associated with Wolff-Parkinson-White syndrome. Ethmozin is a phenothiazine derivative with potent antiarrhythmic effects. Many of these new agents are being used with striking success abroad and at specialized treatment centers for experimental research in the United States.
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