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Desta L, Khedri M, Jernberg T, Andell P, Mohammad MA, Hofman-Bang C, Erlinge D, Spaak J, Persson H. Adherence to beta-blockers and long-term risk of heart failure and mortality after a myocardial infarction. ESC Heart Fail 2020; 8:344-355. [PMID: 33259148 PMCID: PMC7835575 DOI: 10.1002/ehf2.13079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 09/13/2020] [Accepted: 10/13/2020] [Indexed: 12/25/2022] Open
Abstract
Aims The aim of this study is to investigate the association between adherence to beta‐blocker treatment after a first acute myocardial infarction (AMI) and long‐term risk of heart failure (HF) and death. Methods and results All patients admitted for a first AMI included in the nationwide Swedish web‐system for enhancement and development of evidence‐based care in heart disease evaluated according to recommended therapies register between 2005 and 2010 were eligible (n = 71 638). After exclusion of patients who died in‐hospital, patients with previous HF, patients with unknown left ventricular ejection fraction (EF), and patients who died during the first year after the index event, 38 608 patients remained in the final analysis. Adherence to prescribed beta‐blockers was determined for 1 year after the index event using the national registry for prescribed drugs and was measured as proportion of days covered, the ratio between the numbers of days covered by the dispensed prescriptions and number of days in the period. As customary, a threshold level for proportion of days covered ≥80% was used to classify patients as adherent or non‐adherent. At discharge 90.6% (n = 36 869) of all patients were prescribed a beta‐blocker. Among 38 608 1 year survivors, 31.1% (n = 12 013) were non‐adherent to beta‐blockers. Patients with reduced EF with and without HF were more likely to remain adherent to beta‐blockers at 1‐year compared with patients with normal EF without HF (NEF). Being married/cohabiting and having higher income level, hypertension, ST‐elevation MI, and percutaneous coronary intervention were associated with better adherence. Adherence was independently associated with lower all‐cause mortality [hazard ratio (HR) 0.77, 95% confidence interval [CI] 0.71–0.84] and a lower risk for the composite of HF readmission/death, (HR 0.83, 95% CI 0.78–0.89, P value <0.001) during the subsequent 4 years of follow up. These associations were favourable but less apparent in patients with HFNEF and NEF. Conclusions Nearly one in three AMI patients was non‐adherent to beta‐blockers within the first year. Adherence was independently associated with improved long‐term outcomes; however, uncertainty remains for patients with HFNEF and NEF.
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Affiliation(s)
- Liyew Desta
- Department of Cardiology, Heart and Vascular Theme, Karolinska University Hospital, SE-141 86, Stockholm, Sweden
| | - Masih Khedri
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Pontus Andell
- Department of Cardiology, Heart and Vascular Theme, Karolinska University Hospital, SE-141 86, Stockholm, Sweden
| | - Moman Aladdin Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Claes Hofman-Bang
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Hans Persson
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
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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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Nieminen MS, Böhm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, Hasin Y, López-Sendón J, Mebazaa A, Metra M, Rhodes A, Swedberg K. Guías de Práctica Clínica sobre el diagnóstico y tratamiento de la insuficiencia cardíaca aguda. Versión resumida. Rev Esp Cardiol 2005; 58:389-429. [PMID: 15847736 DOI: 10.1157/13073896] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Markku S Nieminen
- Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland. markku.nieminen.hus.fi
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Persson H, Rythe'n-Alder E, Melcher A, Erhardt L. Effects of beta receptor antagonists in patients with clinical evidence of heart failure after myocardial infarction: double blind comparison of metoprolol and xamoterol. BRITISH HEART JOURNAL 1995; 74:140-8. [PMID: 7546992 PMCID: PMC483989 DOI: 10.1136/hrt.74.2.140] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate whether xamoterol, a partial agonist, would improve exercise time more than metoprolol in patients with mild to moderate heart failure after a myocardial infarction. DESIGN Single-centre double blind randomised parallel group comparison of metoprolol 50-100 mg and xamoterol 100-200 mg twice daily. PATIENTS 210 patients aged 40-80 years (173 men) with clinical evidence of heart failure early after a myocardial infarction. 106 were given metoprolol and 104 xamoterol. MAIN OUTCOME MEASURES Exercise test results and performance at three months; the exercise test, quality of life, and clinical assessments at baseline (5-7 days after the infarction) and after 3, 6, and 12 months. RESULTS Exercise time increased at three months by 22% in the metoprolol group and 29% in the xamoterol group, but with no significant difference between the groups. Patients taking xamoterol showed overall non-significantly higher mean values of exercise time achieved with higher heart rates at rest and exercise. Improvements in quality of life, clinical signs of heart failure, and New York Heart Association functional class were seen in both treatment groups over one year, with minor benefits of xamoterol on breathlessness, peripheral oedema, and functional class. Eighteen patients taking metoprolol and 22 taking xamoterol withdrew from the study during one year, with a low mortality, reinfarction rate, and progress of heart failure in both treatment groups. Mean dose from baseline to 3 months was 135 mg metoprolol and 347 mg xamoterol. CONCLUSION beta 1 Receptor antagonists with or without partial agonist activity are safe to use in mild to moderate heart failure after a myocardial infarction. Exercise tolerance, quality of life, and clinical signs and functional class of heart failure improve, and few patients show deterioration in their condition. Exercise tolerance is no better with xamoterol than metoprolol.
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Affiliation(s)
- H Persson
- Section of Cardiology, Karolinska Institute, Danderyd Hospital, Sweden
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Abstract
This article discusses therapy with beta blockade and thrombolytic agents in acute myocardial infarction. In large and well-controlled studies both treatment strategies have been shown to increase survival. Both therapies have also been demonstrated to be safe in acute myocardial infarction. Historically, the 2 different treatment strategies have been tested during different time periods, resulting in few studies with the main objective to study the combined effects of the 2 agents. From the data that are presently available, however, there is a clear suggestion of additive beneficial effect and the 2 treatments given in combination are well tolerated.
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Affiliation(s)
- G Olsson
- Cardiovascular Medicine, Astra Hässle AB, Mölndal, Sweden
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Held P. Effects of beta blockers on ventricular dysfunction after myocardial infarction: tolerability and survival effects. Am J Cardiol 1993; 71:39C-44C. [PMID: 8096674 DOI: 10.1016/0002-9149(93)90085-q] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
At least 44 randomized trials of beta blockade in acute myocardial infarction have been reported. All of these trials excluded patients with moderate-to-severe clinical signs of acute left ventricular dysfunction (LVD). Several of the larger trials did include high-risk patients with a history of compensated heart failure or with symptoms and signs suggesting mild LVD. Data from these trials indicate that beta-blocker treatment was well tolerated by patients with LVD, both in the acute phase of myocardial infarction and during long-term follow-up treatment. Further, data for LVD patients indicate that mortality in the beta-blocker group was reduced by 20-30% when compared with the placebo group. A similar mortality reduction was obtained for the entire patient population in the trials. Because of the high mortality among patients with mild LVD, the absolute gain in numbers of lives saved per 100 patients treated with beta blockers is even larger than that in patients without LVD. Data from two long-term trials indicate marked (47% and 43%) reductions in the likelihood of sudden death among LVD patients treated with beta blockers. These results suggest that all patients with LVD who can tolerate beta blockade may benefit from treatment with these agents.
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Affiliation(s)
- P Held
- Department of Medicine, Ostra Hospital, Götenborg University, Sweden
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Abstract
The use of beta-receptor antagonists in the treatment of heart failure is controversial. Available data do not allow general recommendations regarding their use. In dilated cardiomyopathy, several studies suggest that long-term treatment in individual patients reduces symptoms and increases exercise capacity. Short-term treatment is usually not beneficial, except in patients with ischemically induced left ventricular dysfunction. In heart failure, post myocardial infarction and in chronic ischemic heart disease, no proper long-term study has been performed to evaluate its effects. However, patients with acute myocardial infarction tolerate beta blockers, despite the presence of left ventricular dysfunction and long-term prognosis is improved. Newer agents, some with ancillary properties, such as intrinsic activity and vasodilatation, may have advantages. In the future we need a better description of the cardiac status in our patients in order to be able to select those that will respond favorably to beta-receptor antagonists. The mechanisms by which some patients improve are still obscure. Protection against receptor downregulation, restoration of receptor density, protection against cardiotoxicity of catecholamines, and improvement in ischemic systolic and diastolic left ventricular function are all possible. The fear that beta-receptor antagonists are dangerous in heart failure is in most instances not warranted, but an initial deterioration may have to be accepted in order to gain long-term beneficial effects. Ongoing studies in both idiopathic cardiomyopathy and in postinfarction failure will hopefully help us to define the use of beta-adrenoceptor antagonists in the future.
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Affiliation(s)
- H Persson
- Department of Medicine, Karolinska Institutet, Danderyd Hospital, Sweden
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Blomberg S, Ricksten SE. Effects of thoracic epidural anaesthesia on central haemodynamics compared to cardiac beta adrenoceptor blockade in conscious rats with acute myocardial infarction. Acta Anaesthesiol Scand 1990; 34:1-7. [PMID: 2309537 DOI: 10.1111/j.1399-6576.1990.tb03032.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The study aimed to compare the effects of thoracic epidural anaesthesia (TEA) with those of the beta-adrenoceptor blocker, metoprolol, on central haemodynamics in conscious rats with acute myocardial infarction. During methohexital anaesthesia, appropriate vascular catheters were inserted, a thoracic epidural catheter was implanted and the left coronary artery was ligated. A recovery period of 1-2 h elapsed after termination of surgery and anaesthesia. Experiments were performed on four separate groups of animals (A-D). In Group A (n = 10) mean arterial pressure (MAP), heart rate (HR), and cardiac output (CO) were measured, and stroke volume (SV) and systemic vascular resistance (SVR) were calculated before and 10-15 min after the induction of TEA (bupivacaine 5 mg.ml-1). In Group B (n = 6) left ventricular end-diastolic pressure (LVEDP) and maximal dP/dt were recorded as in Group A. In Group C (n = 10) central haemodynamics were measured 10 min after i.v. metoprolol (0.5 mg.kg-1) and again 10-15 min after the addition of TEA. In Group D (n = 6) LVEDP and max dP/dt were measured as in Group C. The reduction in CO, SV, HR and max dP/dt was of the same magnitude with TEA and metoprolol. TEA lowered MAP by 17%, while metoprolol did not change MAP. Metoprolol caused an increase in LVEDP from 20.8 +/- 1.8 to 27.5 +/- 2.7 mmHg (2.8 +/- 0.2 to 3.7 +/- 0.4 kPa) (P less than 0.01), while TEA induced a decrease in LVEDP from 24.2 +/- 1.4 to 17.8 +/- 1.6 mmHg (3.2 +/- 0.2 to 2.4 +/- 0.2 kPa) (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S Blomberg
- Department of Anaesthesia and Intensive Care, Sahlgrens Hospital, Sweden
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Dell'Italia LJ, Walsh RA. Effect of intravenous metoprolol on left ventricular performance in Q-wave acute myocardial infarction. Am J Cardiol 1989; 63:166-71. [PMID: 2909996 DOI: 10.1016/0002-9149(89)90279-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
To determine the effects of intravenous metoprolol on left ventricular (LV) function in acute myocardial infarction (AMI), 16 patients were studied within 48 hours of Q-wave AMI (mean ejection fraction 47 +/- 6%, mean pulmonary artery wedge pressure 22 +/- 6 mm Hg) with high fidelity pressure and biplane cineventriculography before and after intravenous metoprolol (dose 12 +/- 4 mg). Heart rate decreased from 90 +/- 13 to 74 +/- 11 beats/min (p less than 0.001), pulmonary arterial wedge pressure and LV end-diastolic pressure were unchanged (22 +/- 6 to 21 +/- 6 and 27 +/- 8 to 26 +/- 8 mm Hg, respectively), despite impaired LV relaxation (P = Poe-t/T) after intravenous metoprolol (T from 59 +/- 13 to 72 +/- 12 ms, p less than 0.001). Peak systolic circumferential LV wall stress decreased after beta-adrenergic blockade (330 +/- 93 to 268 +/- 89 g/cm2, p less than 0.05) and LV contractility decreased (dP/dtmax from 1,480 +/- 450 to 1,061 +/- 340 mm Hg/s, p less than 0.001). The ejection fraction decreased (48 +/- 7 to 43 +/- 7%, p less than 0.05) due to an increase in LV end-systolic volume (85 +/- 19 to 93 +/- 19 ml, p less than 0.05) since LV end-diastolic volume was unchanged (161 +/- 30 to 163 +/- 30 ml, difference not significant). In patients with Q-wave AMI, intravenous metoprolol reduces the major determinants of myocardial oxygen demand including heart rate, contractility and peak systolic wall stress. Further, despite decreased heart rate, (+)dP/dtmax, ejection fraction, isovolumic relaxation, LV end-diastolic pressure and end-diastolic volume remain unchanged.
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Affiliation(s)
- L J Dell'Italia
- University of Texas Health Science Center, San Antonio 78284-7872
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Breisblatt WM, Waldo DA, Burns MJ, Spaccavento LJ. Hemodynamic effects of intravenous metoprolol in acute myocardial infarction: the role of anatomic subsets in predicting patient response. Am Heart J 1988; 116:44-9. [PMID: 2839972 DOI: 10.1016/0002-8703(88)90248-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The acute effects of intravenous metoprolol were evaluated in 30 patients with myocardial infarction by means of serial hemodynamic and radionuclide measurements of left ventricular function. Within 1 hour of completion of the metoprolol dosing, 90% of the patients underwent cardiac catheterization to define anatomy and to assess patients for interventional therapy; the remainder had catheterization by 72 hours. All patients tolerated intravenous metoprolol without significant side effects. Patient responses to therapy were divided into two groups based on the angiographic findings. At catheterization, all group 1 patients had visible collaterals to or a patent vessel supplying the vascular distribution of the infarction. All group 2 patients had occluded coronary arteries without evidence of collaterals to the infarct zone. Group 1 (n = 13) improved both systolic and diastolic left ventricular function (mean ejection fraction [EF] = 46% to 55%, peak filling rate [PFR] = 2.1 to 3.2 Edv/sec), while group 2 (n = 17) patients were unchanged (EF = 43% to 42%, PFR = 2.0 to 1.9). Patient characteristics and time to treatment were similar in both groups, as were the hemodynamic effects of metoprolol. Heart rate decreased 20% in group 1 and 22% in group 2 and cardiac output fell 22% in group 1 and 32% in group 2. Acute improvement in ventricular function in these patients appears to be closely related to the coronary anatomy, and in those with flow to the infarct zone, intravenous metoprolol may be effective in preserving left ventricular function.
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Affiliation(s)
- W M Breisblatt
- Cardiology Section, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas
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Abstract
The treatment of mild hypertension has been a subject of controversy because its benefits versus risks are not as well established as they are for moderate to severe hypertension. Results of several studies, however, now show that treatment reduces the frequency of stroke in those with milder blood pressure elevations. New guidelines published by the Joint National Committee recommend that treatment of mild hypertension begin with either a diuretic or a beta blocker. The effect on the most common complication of mild hypertension, that is, coronary heart disease (myocardial infarction and sudden cardiac death), has, however, not been encouraging in studies in which diuretics have been used as first-line treatment. Two large-scale primary preventive studies compared the efficacy of diuretics and beta blockers in reducing coronary heart disease in hypertensive patients; results were in favor of beta blocker regimens in men. So far there is some evidence, but no hard scientific proof, that certain beta blockers offer advantages over diuretics in preventing myocardial infarction and sudden cardiac death in hypertensive patients. A major concern with the use of diuretics is the risk of hypokalemia; this can be reduced when they are combined with beta blockers.
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Vedin A, Wilhelmsson C. The effect and usefulness of early intravenous beta blockade in acute myocardial infarction. PROGRESS IN DRUG RESEARCH. FORTSCHRITTE DER ARZNEIMITTELFORSCHUNG. PROGRES DES RECHERCHES PHARMACEUTIQUES 1986; 30:71-89. [PMID: 2880368 DOI: 10.1007/978-3-0348-9311-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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