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Strauss MH, Hall AS, Narkiewicz K. The Combination of Beta-Blockers and ACE Inhibitors Across the Spectrum of Cardiovascular Diseases. Cardiovasc Drugs Ther 2023; 37:757-770. [PMID: 34533690 PMCID: PMC10397146 DOI: 10.1007/s10557-021-07248-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 02/06/2023]
Abstract
Cardiovascular disease is the leading cause of mortality worldwide, affecting a wide range of patients at different stages across the cardiovascular continuum. Hypertension is one of the earliest risk factors in this continuum and can be controlled in most patients with currently available antihypertensive agents. However, goals are often not met because treatments are not optimized in terms of tailoring therapy to individual patients based on their hypertension subclass and cardiovascular risk profile and initiating early use of adapted-dose, single-pill combinations. In this context, beta-blockers in combination with angiotensin-converting enzyme (ACE) inhibitors are of special interest as a result of their complementary actions on the sympathetic nervous system and renin-angiotensin-aldosterone system, two interlinked pathways that influence cardiovascular risk and disease outcomes. In addition to their antihypertensive actions, beta-blockers are used to manage arrhythmias and treat angina pectoris and heart failure, while ACE inhibitors provide cardioprotection in patients with acute coronary syndromes and treat congestive heart failure. A broad range of patients may therefore receive the combination in routine clinical practice. This paper examines the supporting evidence for beta-blockers and ACE inhibitors in each of the above indications and considers the rationale for combining these agents into a single pill, using data from bisoprolol and perindopril randomized controlled trials as supporting evidence. Combining these established antihypertensive agents into a single pill continues to provide effective blood pressure lowering and improved cardiovascular outcomes while allowing a greater proportion of patients to rapidly achieve treatment targets.
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Affiliation(s)
- Martin H Strauss
- University of Toronto, North York General Hospital, Toronto, ON, Canada.
| | | | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Faculty of Medicine, Medical University of Gdansk, Debinki 7c, 80-952, Gdansk, Poland
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Kobalava Z, Kvasnikov B, Burtsev Y. Effectiveness and Tolerability of Bisoprolol/Perindopril Single-Pill Combination in Patients with Arterial Hypertension and a History of Myocardial Infarction: The PRIDE Observational Study. Adv Ther 2023; 40:2725-2740. [PMID: 37029871 PMCID: PMC10220120 DOI: 10.1007/s12325-023-02462-9] [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: 11/10/2022] [Accepted: 02/13/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION This study assessed the real-life effectiveness of a single-pill combination (SPC) of bisoprolol/perindopril for controlling blood pressure (BP) and symptoms of angina in patients with hypertension and a history of myocardial infarction (MI). METHODS Eligible patients with arterial hypertension and a history of MI were aged 18-79 years and had initiated bisoprolol/perindopril SPC within 3 months of study enrollment as part of routine Russian clinical practice. The primary endpoint was mean change in systolic and diastolic BP (SBP/DBP) at week 12 compared with baseline (data collected retrospectively). Secondary endpoints were assessed at weeks 4 and 12 and included mean change in resting heart rate (HR), proportion of patients reaching target level of resting HR, antianginal effectiveness of the SPC, and proportion of patients reaching target BP levels. RESULTS A total of 504 patients were enrolled, of whom 481 comprised the full analysis set (mean age 61.4 ± 8.9 years, 68% men). Mean baseline SBP/DBP and HR values were 148.9 ± 16.8/87.7 ± 11.0 mmHg and 77.4 ± 10.5 bpm, respectively. Mean durations of hypertension and CAD were 12.8 ± 8.4 and 6.1 ± 6.3 years, respectively, and time since MI was 3.8 ± 5.3 years. At week 12, SBP/DBP had decreased by 24.9/12.2 mmHg (P < 0.001 vs baseline). Target BP (< 140/90 mmHg) was achieved by 69.8% and 95.9% of patients at weeks 4 and 12, respectively, and target HR (55-60 bpm) by 17.3% and 34.5% at weeks 4 and 12 versus 3.1% at baseline (P < 0.001). Reductions in angina attacks, nitrate consumption, and improvements in HR were statistically significant. Treatment was well tolerated. CONCLUSION Treatment of symptomatic patients with CAD, hypertension, and a history of MI with a bisoprolol/perindopril SPC was associated with significant decreases in SBP/DBP and a high proportion of patients achieving BP treatment goals. This was accompanied by improvements in angina symptoms and reductions in HR in a broad patient population representative of those seen in everyday clinical practice. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT04656847.
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Affiliation(s)
| | - Boris Kvasnikov
- Department of Medical Affairs, Servier Russia, Moscow, Russia
| | - Yuriy Burtsev
- Department of Medical Affairs, Servier Russia, Moscow, Russia
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(Why to use fixed dose perindopril, bisoprolol combination in hypertonics with CHD?). COR ET VASA 2023. [DOI: 10.33678/cor.2023.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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AlHabeeb W, Mrabeti S, Abdelsalam AAI. Therapeutic Properties of Highly Selective β-blockers With or Without Additional Vasodilator Properties: Focus on Bisoprolol and Nebivolol in Patients With Cardiovascular Disease. Cardiovasc Drugs Ther 2021; 36:959-971. [PMID: 34106365 PMCID: PMC9519665 DOI: 10.1007/s10557-021-07205-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 02/07/2023]
Abstract
Bisoprolol and nebivolol are highly selective β1-adrenoceptor antagonists, with clinical indications in many countries within the management of heart failure with reduced left ventricular ejection fraction (HFrEF), ischaemic heart disease (IHD), and hypertension. Nebivolol has additional vasodilator actions, related to enhanced release of NO in the vascular wall. In principle, this additional mechanism compared with bisoprolol might lead to more potent vasodilatation, which in turn might influence the effectiveness of nebivolol in the management of HFrEF, IHD and hypertension. In this article, we review the therapeutic properties of bisoprolol and nebivolol, as representatives of “second generation” and “third generation” β-blockers, respectively. Although head-to-head trials are largely lacking, there is no clear indication from published studies of an additional effect of nebivolol on clinical outcomes in patients with HFrEF or the magnitude of reductions of BP in patients with hypertension.
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Affiliation(s)
- Waleed AlHabeeb
- Cardiac Sciences Department, King Saud University, Riyadh, 12372, Saudi Arabia.
| | - Sanaa Mrabeti
- General Medicine and Endocrinology, Medical Affairs EMEA, Merck Serono Middle East FZ-LLC, Dubai, United Arab Emirates
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Pathak A, Mrabeti S. β-Blockade for Patients with Hypertension, Ischemic Heart Disease or Heart Failure: Where are We Now? Vasc Health Risk Manag 2021; 17:337-348. [PMID: 34135591 PMCID: PMC8197620 DOI: 10.2147/vhrm.s285907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
β-blockers are a heterogeneous class of drugs, with varying selectivity/specificity for β1 vs β2 receptors, intrinsic sympathomimetic activity (ISA), and vasodilatory properties (through β2 stimulation, α receptor blockade or nitric oxide release). These drugs are indicated for the management of arterial hypertension, heart failure or ischemic heart disease (IHD; eg angina pectoris or prior myocardial infarction). Most of the benefit of β-blockade in these conditions arises from blockade of the β1 receptor, and, in practice, the addition of ISA appears to reduce the potential for improved clinical outcomes in people with heart failure or IHD. Aspects of the benefit/risk balance of β-blockers remain controversial, and recent meta-analyses have shed new light on this issue. We have reviewed the current place of cardioselective β-blockade in hypertension, IHD and heart failure, with special reference to the therapeutic profile of a highly selective β1-adrenoceptor blocker, bisoprolol.
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Affiliation(s)
- Atul Pathak
- Department of Cardiovascular Medicine, Centre Hospitalier Princesse Grace, Monaco
| | - Sanaa Mrabeti
- Medical Affairs EMEA, Merck Serono Middle East FZ-LLC, Dubai, United Arab Emirates
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Boytsov SA, Burtsev YP, Khomitskaya YV, Karpov YA. Effectiveness and Tolerability of the Single-Pill Combination of Bisoprolol and Perindopril in Patients with Arterial Hypertension and Stable Coronary Artery Disease in Daily Clinical Practice: The STYLE Study. Adv Ther 2021; 38:3299-3313. [PMID: 33991323 PMCID: PMC8189988 DOI: 10.1007/s12325-021-01754-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/19/2021] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Combination antihypertensive therapy is required by most patients to achieve guideline-recommended blood pressure (BP) goals. This study assessed the effectiveness and tolerability of bisoprolol/perindopril (Bis/Per) single-pill combination (SPC) in Russian patients with hypertension and coronary artery disease (CAD) treated in routine clinical practice. METHODS STYLE (NCT03730116) was an open-label, uncontrolled, prospective observational study conducted in patients who were already receiving Bis/Per SPC, switched to SPC from Bis or Per monotherapy, or switched from a free combination of Bis and Per. Primary endpoint criteria were assessed at 1 and 3 months and included change in mean office systolic/diastolic blood pressure (SBP/DBP), proportion achieving target BP (< 140/90 mmHg), and measures of antianginal effectiveness. RESULTS The full analysis set comprised 1892 subjects. Mean age was 61.9 ± 8.8 years, 53.2% were women, and mean durations of hypertension and CAD were 12.5 ± 7.9 and 7.2 ± 6.4 years, respectively. Mean SBP/DBP decreased by 22.3/11.0 mmHg and 31.5/15.9 mmHg at 1 and 3 months, respectively (P < 0.0001 vs baseline). Target BP was achieved by 49.2% and 86.7% of patients at 1 and 3 months, respectively. Reductions in mean number of angina attacks and nitrate consumption and improvements in heart rate were statistically significant. Treatment was well tolerated. CONCLUSION Treatment of patients with hypertension and CAD with Bis/Per SPC for 3 months was associated with significant decreases in SBP/DBP and a high proportion of patients achieving BP treatment goals. This was accompanied by an improvement in angina symptoms. Treatment was well tolerated in a broad patient population representative of those seen in everyday clinical practice.
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Affiliation(s)
- Sergey A Boytsov
- Department of Angiology, National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - Yuri P Burtsev
- Department of Medical Affairs, Servier Russia, Moscow, Russia
| | | | - Yuri A Karpov
- Department of Angiology, National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia.
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Shitara J, Naito R, Kasai T, Endo H, Wada H, Doi S, Konishi H, Tsuboi S, Ogita M, Dohi T, Okazaki S, Miyauchi K, Daida H. Differing effects of beta-blockers on long-term clinical outcomes following percutaneous coronary intervention between patients with mid-range and reduced left ventricular ejection fraction. BMC Cardiovasc Disord 2021; 21:36. [PMID: 33446110 PMCID: PMC7809870 DOI: 10.1186/s12872-021-01850-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this study was to determine the difference in effects of beta-blockers on long-term clinical outcomes between ischemic heart disease (IHD) patients with mid-range ejection fraction (mrEF) and those with reduced ejection fraction (rEF). Methods Data were assessed of 3508 consecutive IHD patients who underwent percutaneous coronary intervention (PCI) between 1997 and 2011. Among them, 316 patients with mrEF (EF = 40–49%) and 201 patients with rEF (EF < 40%) were identified. They were assigned to groups according to users and non-users of beta-blockers and effects of beta-blockers were assessed between mrEF and rEF patients, separately. The primary outcome was a composite of all-cause death and non-fatal acute coronary syndrome. Results The median follow-up period was 5.5 years in mrEF patients and 4.3 years in rEF patients. Cumulative event-free survival was significantly lower in the group with beta-blockers than in the group without beta-blockers in rEF (p = 0.003), whereas no difference was observed in mrEF (p = 0.137) between those with and without beta-blockers. In the multivariate analysis, use of beta-blockers was associated with reduction in clinical outcomes in patients with rEF (hazard ratio (HR), 0.59; 95% confidence interval (CI), 0.36–0.97; p = 0.036), whereas no association was observed among those with mrEF (HR 0.74; 95% CI 0.49–1.10; p = 0.137). Conclusions Our observational study showed that use of beta-blockers was not associated with long-term clinical outcomes in IHD patients with mrEF, whereas a significant association was observed in those with rEF.
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Affiliation(s)
- Jun Shitara
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Ryo Naito
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan. .,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan. .,Sleep and Sleep Disordered Breathing Center, Juntendo University Hospital, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Hirohisa Endo
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Shinichiro Doi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hirokazu Konishi
- Department of Cardiology, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Shuta Tsuboi
- Department of Cardiology, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Manabu Ogita
- Department of Cardiology, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Tomotaka Dohi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Shinya Okazaki
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Katsumi Miyauchi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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Grigoryeva NY, Vilkova OE, Samolyuk MO, Kolosova KS. [New opportunities to improve the treatment effectiveness of patients with stable angina]. ACTA ACUST UNITED AC 2020; 60:1135. [PMID: 32720615 DOI: 10.18087/cardio.2020.6.n1135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/12/2020] [Indexed: 11/18/2022]
Abstract
Aim To study the antianginal and heart rate slowing effects in patients with stable angina (SA) who failed to achieve the heart rate (HR) goal and were switched from the beta-blocker (BB) metoprolol tartrate to a combination of metoprolol tartrate and ivabradine.Materials and methods The study included 54 patients with SA not higher than functional class (FC) III (35 (64.8 %) men and 19 (35.2 %) women) aged 59 [48; 77] years. Prior to the study start and at 4 and 8 weeks of follow-up, electrocardiography (ECG) and 24-h ECG monitoring (24h-ECGM) were performed for all patients. The follow-up period duration was 8 weeks. The antianginal and heart rate slowing effects of therapy were clinically evaluated by a decrease in frequency of anginal attacks and patients' requirement for nitrates, a decrease in HR, and the effect on 24h-ECGM indexes characterizing myocardial ischemia. At the first stage, all patients were prescribed metoprolol tartrate (Egilok®, Egis, Hungary) 25 mg twice a day. Patients with resting HR still higher than 70 bpm after 4 weeks of treatment were switched from metoprolol tartrate to a fixed ivabradine/metoprolol combination (Implicor®, Servier, France) 5 / 25 mg twice a day. Thus, based on achieving/ non-achieving the HR goal, two groups of patients were formed. Statistical analysis was performed with a STATISTICA 10,0 software package.Results After 4 weeks of therapy with metoprolol tartrate 25 mg twice a day, 18 (33.3%) patients of group 1 achieved the HR goal of 70 bpm, while 36 (66.7%) patients of group 2 did not achieve the goal. For further correction of HR, patients of group 2 were switched from metoprolol tartrate to ivabradine/metoprolol 5 / 25 mg twice a day. After 4 weeks of the ivabradine/metoprolol treatment, 31 (86.1 %) patients achieved the HR goal with median resting HR of 62 [56; 70] bpm. The number of angina attacks decreased from 6 [3; 8] to 2 [1; 3] per week (р<0.001). 24hECGM showed that the mean diurnal HR decreased from 81 [76; 96] to 66 [56; 76] bpm (р<0.001); mean night HR decreased from 69 [73; 80] to 52 [43; 60] bpm (р=0.012); and the ischemic ST segment depression was absent.Conclusion Only 33.3% of patients with stable angina achieved the HR goal on metoprolol tartrate 25 mg twice a day. Supplementing the beta-blocker metoprolol tartrate at the same dose with ivabradine allowed 86.1% of patients to achieve the HR goal and exerted a pronounced anti-anginal effect.
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Affiliation(s)
- N Yu Grigoryeva
- Federal State Budgetary Educational Institution of Higher Education «Privolzhsky Research Medical University» of the Ministry of Health of the Russian Federation, Nizhny Novgorod
| | - O E Vilkova
- Federal State Budgetary Educational Institution of Higher Education «Privolzhsky Research Medical University» of the Ministry of Health of the Russian Federation, Nizhny Novgorod
| | - M O Samolyuk
- Federal State Budgetary Educational Institution of Higher Education «Privolzhsky Research Medical University» of the Ministry of Health of the Russian Federation, Nizhny Novgorod
| | - K S Kolosova
- Federal State Budgetary Educational Institution of Higher Education «Privolzhsky Research Medical University» of the Ministry of Health of the Russian Federation, Nizhny Novgorod
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Won H, Suh Y, Kim GS, Ko YG, Hong MK. Clinical Impact of Beta Blockers in Patients with Myocardial Infarction from the Korean National Health Insurance Database. Korean Circ J 2020; 50:499-508. [PMID: 32096355 PMCID: PMC7234850 DOI: 10.4070/kcj.2019.0231] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/29/2019] [Accepted: 12/04/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Whether beta blockers favorably impact the clinical outcome in patients with acute myocardial infarction (AMI) remains in debate. We investigated the impact of beta blocker on major clinical outcomes during 2 years after percutaneous coronary intervention (PCI) in patients with AMI. METHODS All patients with the first AMI treated with PCI for the period of 2005 to 2014 from the Korean National Health Insurance Service claims database were enrolled. We defined the regular user as medication possession ratio (MPR) ≥80% and non-user as MPR=0%. We compared the occurrence of all cause death, myocardial infarction (MI) and stroke according to adherence of beta-blockers. A 1:1 propensity score-matching was conducted to adjust for between-group differences. RESULTS We identified a total 81,752 patients with met eligible criteria. At discharge, 63,885 (78%) patients were prescribed beta blockers. For 2 years follow up period, regular users were 53,991 (66%) patients, non-users were 10,991 (13%). In the propensity score matched population, regular use of beta blocker was associated with a 36% reduced risk of composite adverse events (all death, MI or stroke) (hazard ratio [HR], 0.636; 95% confidence interval [CI], 0.555-0.728; p<0.001). Compared to no use of beta blocker, regular use significantly reduced all death (HR, 0.736; 95% CI, 0.668-0.812; p<0.001), MI (HR, 0.729; 95% CI, 0.611-0.803; p<0.001) and stroke (HR, 0.717; 95% CI, 0.650-0.791; p<0.001). CONCLUSIONS Prescription of beta blocker in patients with AMI after PCI was sequentially increased. Continuous regular use of beta blocker for 2 years after AMI reduced major adverse events compared to no use of beta blocker.
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Affiliation(s)
- Hoyoun Won
- Cardiovascular & Arrhythmia Center, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Yongsung Suh
- Department of Cardiology, Myongji Hospital, Goyang, Korea
| | - Gwang Sil Kim
- Department of Cardiology, Sanggye-Paik Hospital, Inje Universiy College of Medicine, Seoul, Korea
| | - Young Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea.,Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Myeong Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea.,Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Martínez-Milla J, Raposeiras-Roubín S, Pascual-Figal DA, Ibáñez B. Papel de los bloqueadores beta en la enfermedad cardiovascular en 2019. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2019.02.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Martínez-Milla J, Raposeiras-Roubín S, Pascual-Figal DA, Ibáñez B. Role of Beta-blockers in Cardiovascular Disease in 2019. ACTA ACUST UNITED AC 2019; 72:844-852. [PMID: 31402328 DOI: 10.1016/j.rec.2019.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/24/2019] [Indexed: 11/17/2022]
Abstract
Beta-blockers are the cornerstone of treatment for various cardiovascular conditions. Although their effects have classically been considered to be driven by their antagonistic and competitive action on beta-adrenergic receptors, nowadays it is known that their effect goes beyond that of mere competition with catecholamines on these receptors. Beta-blockers were discovered as antianginal drugs in the 1960s and are currently widely used in heart failure, arrhythmias, and ischemic heart disease. In this article, we review the evidence for the beneficial effects of beta-blockers in these conditions, as well as the current recommendations in clinical practice guidelines for their use. Surprisingly, despite having been prescribed for more than 4 decades, new, previously unnoticed mechanisms of action on cellular compartments are still being discovered, which continues to open up new horizons for their use. All in all, beta-blockers are one of the most fascinating drug groups in our therapeutic armamentarium.
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Affiliation(s)
- Juan Martínez-Milla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
| | | | - Domingo A Pascual-Figal
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Universidad de Murcia, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Borja Ibáñez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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Sabidó M, Thilo H, Guido G. Long-term effectiveness of bisoprolol in patients with angina: A real-world evidence study. Pharmacol Res 2018; 139:106-112. [PMID: 30408572 DOI: 10.1016/j.phrs.2018.10.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/25/2018] [Accepted: 10/31/2018] [Indexed: 10/27/2022]
Abstract
A cohort analysis using UK Clinical Practice Research Datalink (CPRD) was performed to compare the effects of bisoprolol, other β-blockers, and drugs other than β-blockers on the long-term risk of mortality and cardiovascular events in patients with angina. Adult patients first diagnosed with angina from 2000 to 2014, with ≥365 days of registration to first angina diagnosis and initiating monotherapies of bisoprolol, other β-blockers, or drugs other than β-blockers within 6 months of angina diagnosis were included. Incidence rates for each treatment cohort were compared using adjusted hazard ratio (HR) and 95% confidence intervals (CI) obtained from Cox regression analyses. Overall, 987 patients were treated with bisoprolol, 1348 with other β-blockers and 5272 with drugs other than β-blockers. Over the total follow-up (≤14 years), the HR of bisoprolol versus other β-blockers and drugs other than β-blockers for mortality was 0.45 (95% CI: 0.34-0.61) and 0.50 (95% CI: 0.38-0.66), respectively. The HR of bisoprolol versus other β-blockers for angina was 0.58 (95% CI: 0.50-0.68) and versus drugs other than β-blockers was 0.77 (95% CI: 0.68-0.88), respectively. For myocardial infarction, the HR of bisoprolol versus drugs other than β-blockers up to 14 years was 0.34 (95% CI: 0.23-0.52) and versus other β-blockers up to 5 years was 0.45 (95% CI: 0.27-0.75). At 5 years, the HR of bisoprolol versus other β-blockers, and drugs other than β-blockers, for arrhythmia was 0.60 (95% CI: 0.35-1.0) and 0.61 (95% CI: 0.40-0.93), respectively. In conclusion, long-term significant reduction in the risk of mortality and various cardiovascular events with bisoprolol versus other β-blockers, and drugs other than β-blockers, confirm treatment guidelines recommendation that bisoprolol is particularly well suited as the first-line treatment of angina in primary care.
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Affiliation(s)
- M Sabidó
- Merck KGaA, Frankfurter Strasse 250, Darmstadt, 64293, Germany.
| | | | - Grassi Guido
- Clinica Medica, University Milano Bicocca, Milan, Italy; IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
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Tsai MS, Tang CH, Lin CY, Chuang PY, Chen NC, Huang CH, Chang WT, Wang TD, Yu PH, Chen WJ. Diuretic or Beta-Blocker for Hypertensive Patients Already Receiving ACEI/ARB and Calcium Channel Blocker. Cardiovasc Drugs Ther 2017; 31:535-543. [PMID: 29218625 DOI: 10.1007/s10557-017-6765-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND In patients already receiving combination of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) and calcium channel blocker (CCB), whether the choice of additional diuretic or beta-blocker affects the cardiovascular and cerebrovascular outcomes remains unclear. METHODS A total of 13,551 patients who were concurrently receiving three anti-hypertensive agents of different classes through outpatient clinics during 2004-2006 were identified from the National Health Insurance Research Database of Taiwan. Patients were further classified into two treatment groups according to the medication possession ratio of drug combinations; the A + B + C group as those who received concurrent therapy of ACEI/ARB, beta-blocker and CCB. The A + C + D group as patients who received ACEI/ARB, CCB, and diuretics. The event-free survival of stroke, acute myocardial infarction (AMI), mortality, and major adverse cardiovascular events (MACE) between the two treatment groups was investigated. RESULTS After propensity score matching, there were 5120 patients in each group. There were no differences in the incidence of cardiovascular events between the two groups. In patients with prior history of cerebrovascular accident (CVA), the A + C + D group had a significantly higher AMI-free survival (adjusted HR = 1.56; 95% CI 1.051-2.307; p < 0.05) as compared with the A + B + C group. CONCLUSION Adding a diuretic may be better than adding a beta-blocker for treating hypertensive patients with prior CVA history who have already received ACEIs/ARBs and CCBs.
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Affiliation(s)
- Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, No. 7, Chung-Shan S. Road, Taipei, Taiwan, 100.,Department of Emergency Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chao-Hsiun Tang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.
| | - Chia-Ying Lin
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Po-Ya Chuang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Nai-Chuan Chen
- Department of Emergency Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan County, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, No. 7, Chung-Shan S. Road, Taipei, Taiwan, 100
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, No. 7, Chung-Shan S. Road, Taipei, Taiwan, 100
| | - Tzung-Dau Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Ping-Hsun Yu
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, No. 7, Chung-Shan S. Road, Taipei, Taiwan, 100.
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Noble S, Roffi M. Routine beta-blocker administration following acute myocardial infarction: why still an unsolved issue? J Thorac Dis 2017; 9:4191-4194. [PMID: 29268468 PMCID: PMC5721004 DOI: 10.21037/jtd.2017.10.25] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 10/01/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Stephane Noble
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland
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15
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Padala SK, Lavelle MP, Sidhu MS, Cabral KP, Morrone D, Boden WE, Toth PP. Antianginal Therapy for Stable Ischemic Heart Disease. J Cardiovasc Pharmacol Ther 2017; 22:499-510. [DOI: 10.1177/1074248417698224] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic angina pectoris is associated with considerable morbidity and mortality, especially if treated suboptimally. For many patients, aggressive pharmacologic intervention is necessary in order to alleviate anginal symptoms. The optimal treatment of stable ischemic heart disease (SIHD) should be the prevention of angina and ischemia, with the goal of maximizing both quality and quantity of life. In addition to effective risk factor modification with lifestyle changes, intensive pharmacologic secondary prevention is the therapeutic cornerstone in managing patients with SIHD. Current guidelines recommend a multifaceted therapeutic approach with β-blockers as first-line treatment. Another important pharmacologic intervention for managing SIHD is nitrates. Nitrates can provide both relief of acute angina and can be used prophylactically before exposure to known triggers of myocardial ischemia to prevent angina. Additional therapeutic options include calcium channel blockers and ranolazine, an inhibitor of the late inward sodium current, that can be used alone or in addition to nitrates or β-blockers when these agents fail to alleviate symptoms. Ranolazine appears to be particularly effective for patients with microvascular angina and endothelial dysfunction. In addition, certain antianginal therapies are approved in Europe and have been shown to improve symptoms, including ivabradine, nicorandil, and trimetazidine; however, these have yet to be approved in the United States. Ultimately, there are several different medications available to the physician for managing the patient with SIHD having chronic angina, when either used alone or in combination. The purpose of this review is to highlight the most important therapeutic approaches to optimizing contemporary treatment in response to individual patient needs.
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Affiliation(s)
- Santosh K. Padala
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Mandeep S. Sidhu
- Department of Medicine, Albany Medical College, Albany, NY, USA
- Albany Stratton VA Medical Center and Albany Medical Center, Albany, NY, USA
| | | | - Doralisa Morrone
- Surgery, Medicine, Molecular, and Critical Area Department, Cardiac-Cardiovascular Disease Section, University of Pisa, Pisa, Italy
| | - William E. Boden
- Department of Medicine, Albany Medical College, Albany, NY, USA
- Albany Stratton VA Medical Center and Albany Medical Center, Albany, NY, USA
| | - Peter P. Toth
- Department of Preventive Cardiology, CGH Medical Center, Sterling, IL, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Chronic stable angina is a significant problem in older adults. The goal of therapy is to provide symptomatic relief, improve patient quality of life, and prevent subsequent angina or myocardial infarction that could lead to sudden death. The efficacy and safety of drugs such as beta-blockers and calcium channel blockers for managing chronic stable angina in older adults has not been rigorously investigated. Drug selection should be based on physiologic alterations, patient comorbidities, adverse reaction profile, and cost.
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18
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Andersson C, Shilane D, Go AS, Chang TI, Kazi D, Solomon MD, Boothroyd DB, Hlatky MA. Beta-Blocker Therapy and Cardiac Events Among Patients With Newly Diagnosed Coronary Heart Disease. J Am Coll Cardiol 2014; 64:247-52. [DOI: 10.1016/j.jacc.2014.04.042] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 04/23/2014] [Accepted: 04/25/2014] [Indexed: 10/25/2022]
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Kobalava Z, Khomitskaya Y, Kiyakbaev G. AchievemenT of target resting HEart rate on beta-blockers in patients with stable angiNA and hypertension (ATHENA) in routine clinical practice in Russia. Curr Med Res Opin 2014; 30:805-11. [PMID: 24400847 DOI: 10.1185/03007995.2013.874993] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The primary objective of this study was to establish the proportion of patients with stable angina and arterial hypertension on beta-blocker (BB) treatment reaching target resting heart rates (RHR) of 55-60 beats per min in clinical cardiology and general practice in Russia. Secondary objectives included the association between achievement of target RHR and mean BB doses, Seattle Angina Questionnaire (SAQ) scores and achievement of target blood pressure (BP) levels (systolic/diastolic BP <140/90 mmHg). RESEARCH DESIGN AND METHODS ATHENA (AchievemenT of target resting HEart rate on beta-blockers in patients with stable angiNA and hypertension) was a non-interventional, cross-sectional, observational study conducted in 20 sites in Russia (NCT01321242). The study population comprised patients aged ≥18 years with stable angina (class I-III) and primary hypertension, on BB treatment for ≥2 months prior to enrollment. RESULTS Of 399 study participants, 62 (15.5%; 95% confidence interval [CI]: 0.121 to 0.195) achieved target RHR. Clinical characteristics associated with significant differences between subgroups achieving and not achieving target RHR were systolic BP (131.1 vs 138.2 mmHg, P = 0.006), diastolic BP (78.6 vs 83.5 mmHg, P < 0.001) and frequency of nitroglycerin administration (1.5% vs 3.0%, P = 0.045). Most patients were taking bisoprolol (48.9%) and metoprolol (36.1%), with mean daily doses of 5.5 mg and 73.7 mg, respectively. Median SAQ scores were: 52.8 physical limitation, 50.0 angina stability, 60.0 angina frequency, 75.0 treatment satisfaction, 50.0 disease perception (quality of life) and 59.6 total score, with no significant differences between subgroups. Patients achieving target RHR were significantly more likely also to achieve target BP, compared with patients not achieving target RHR (72.6% vs 53.4%; P = 0.005; odds ratio: 2.309; 95% CI: 1.270 to 4.197). CONCLUSION In a Russian population with stable angina and hypertension on BB treatment, RHR control was suboptimal. ClinicalTrials.gov identifier: NCT01321242.
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Affiliation(s)
- Zhanna Kobalava
- Peoples' Friendship University of Russia , Moscow , Russian Federation
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20
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1227] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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21
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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22
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Fendrikova AV, Skibitskyi VV. Effectiveness of the original trimetazidine MR in patients with stable coronary heart disease and angina attacks resistant to trimetazidine generics (ETALON study). КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2011. [DOI: 10.15829/1728-8800-2011-4-96-100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To assess the clinical benefits of the original trimetazidine medication (Preductal® MR) in patients with stable coronary heart disease and angina attacks resistant to trimetazidine generics. Material and methods. The study included 112 patients with stable coronary heart disease (CHD), who experienced angina attacks, despite the treatment with trimetazidine generics added to the standard CHD therapy (antiaggregants, statins, β-аadrenoblockers, ACE inhibitors). All participants received Preductal® MR (35 mg twice a day) instead of trimetazidine generics. The follow-up duration was 3 months. Treatment effectiveness was assessed by the changes in angina attack incidence, short-acting nitrate consumption, and general status, using a visual analogue scale (VAS). In addition, pharmaco-economic analysis of the treatment effectiveness was performed. Results. The replacement of trimetazidine generics with Preductal® MR was associated with a reduction in angina attack incidence by 63 % and in the number of nitroglycerine tablets/doses by 65 % (p<0,01). VAS score increased from 45,3±13,8 to 71,6±11,9 (р<0,0001). Preductal® MR therapy is the best pharmaco-economic option, since the ratio between weekly treatment costs (RUB) and the weekly number of prevented angina attacks is minimal for this original medication. Conclusion. In patients with stable CHD and angina attacks, resistant to trimetazidine generics, Preductal® МR therapy is associated with a significant reduction in angina attack incidence and consumption of short-acting nitrates. Preductal® MR is the most cost-effective medication, providing optimal effectiveness with minimal costs.
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23
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Tomlinson B, Dalal JJ, Huang J, Low LP, Park CG, Rahman AR, Reyes EB, Soenarta AA, Heagerty A, Follath F. The role of β-blockers in the management of hypertension: an Asian perspective. Curr Med Res Opin 2011; 27:1021-33. [PMID: 21410302 DOI: 10.1185/03007995.2011.562884] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Following publication of the National Institute of Clinical Excellence (NICE) Guidelines in 2006, the use of β-blockers as first-line therapy in hypertension has been somewhat controversial. However, a recent reappraisal of the European Society of Hypertension guidelines highlights that these agents exhibit similar BP lowering efficacy to other classes of agents, prompting a re-examination of the utility of these agents in various patient populations. The authors felt that it is important to address this controversy and provide an Asian perspective on the place of β-blockers in current clinical practice and the benefits of β-blockade in selected patient populations. In addition to their use as a potential first-line therapy in uncomplicated hypertension, β-blockers have a particular role in patients with hypertension and comorbidities such as heart failure or coronary artery disease, including those who had a myocardial infarction. One advantage which β-blockers offer is the additional protective effects in patients with prior cardiovascular events. Some of the disadvantages attributed to β-blockers appear more related to the older drugs in this class and further appraisal of the efficacy and safety profile of newer β-blockers will lend support to the current guideline recommendations in Asian countries and encourage increased appropriate use of β-blockade in current clinical practice within Asia.
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Affiliation(s)
- B Tomlinson
- Department of Medicine and Therapeutics; Division of Clinical Pharmacology, The Chinese University of Hong Kong, Hong Kong SAR.
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24
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Shu DF, Dong BR, Lin XF, Wu TX, Liu GJ. Long-term beta blockers for stable angina: systematic review and meta-analysis. Eur J Prev Cardiol 2011; 19:330-41. [PMID: 22779086 DOI: 10.1177/1741826711409325] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objectives: To assess the effects of long-term beta blockers in patients with stable angina. Methods: We reviewed the literature up to June 2010 from CENTRAL, MEDLINE, EMBASE, CBM, and CNKI for randomized controlled trials. The appropriate data were meta-analysed using Revman 5.0. Results: Twenty-six trials including 6108 patients were identified. The treatment with beta blockers has significantly decreased all-cause mortality when compared with no control (OR 0.40, 95% CI 0.20 to 0.79), but has had no statistically differences when compared with placebo (OR 0.92, 95% CI 0.62 to 1.38) and with calcium-channel blocker (CCB) (OR 0.84, 95% CI 0.49 to 1.44). This was similar in patients with fatal and non-fatal acute myocardial infarction when compared with placebo (OR 0.82, 95% CI 0.57 to 1.17) or CCB (OR 1.08, 95% CI 0.71 to 1.66); on revascularization and quality of life. The beta blockers reduced the incident of unstable angina compared to no treatment (OR 0.14, 95% CI 0.07 to 0.29), but increased unstable angina compared to placebo (OR 3.32, 95% CI 1.50 to 7.36). There was a significant reduction of nitrate consumption when beta blockers were compared with CCBs (OR −1.18, 95% CI −1.54 to −0.82), but not with placebo and trimetazidine. There was no significant difference in angina attack between each group. Side effects in beta blocker were similar with ones in controls. Conclusions: Beta blockers may decrease the death and unstable angina when compared with no treatment, but no more effective than other anti-anginal agents on prophylaxis of myocardial ischaemia in stable angina patients.
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Affiliation(s)
- De Fen Shu
- Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Bi Rong Dong
- Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiu Fang Lin
- Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Tai Xiang Wu
- Chinese Cochrane Centre, Chinese EBM Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Guan Jian Liu
- Chinese Cochrane Centre, Chinese EBM Centre, West China Hospital, Sichuan University, Chengdu, China
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Kohro T, Hayashi D, Yamazaki T, Nagai R, The JCAD Investigators. Beta-Blocker Prescription Among Japanese Cardiologists and Its Effect on Various Outcomes. Circ J 2010; 74:962-9. [DOI: 10.1253/circj.cj-09-0613] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takahide Kohro
- Department of Translational Research for Healthcare and Clinical Science, The University of Tokyo
| | - Dobun Hayashi
- Department of Cardiovascular Medicine, The University of Tokyo
| | - Tsutomu Yamazaki
- Department of Clinical Epidemiology & Systems, Graduate School of Medicine, The University of Tokyo
| | - Ryozo Nagai
- Department of Cardiovascular Medicine, The University of Tokyo
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26
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Abstract
The clinical syndrome of chronic stable angina is an age-related condition that is one common manifestation of coronary artery disease (CAD). The presence of angina significantly affects quality of life when patients must limit their activities of daily living in an effort to prevent the occurrence of anginal attacks. In addition, patients are at risk for significant complications of CAD such as myocardial infarction, heart failure, stroke, and death. Therefore, treatment should focus not only on relief of symptoms and improvements in quality of life, but also on preventing disease progression and reducing the risk of complications from CAD. All patients should be instructed on the appropriate use of sublingual nitroglycerin for the immediate treatment of anginal episodes. Beta-blockers, calcium channel blockers, long-acting nitrate therapy, and ranolazine can prevent anginal symptoms. In addition, aggressive risk factor management, healthy lifestyle changes, antiplatelet agents such as aspirin, and angiotensin-converting enzyme inhibitors all should be used to prevent disease progression and occurrence of myocardial infarction or death. Many patients will be candidates for revascularization of the myocardium with either percutaneous coronary intervention or coronary artery bypass grafting for relief of symptoms as well as improvement in prognosis. Even after revascularization, patients may still require antianginal drug therapy. All patients undergoing revascularization should be guided to make appropriate lifestyle changes and to make concerted efforts to manage risk factors for CAD.
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Affiliation(s)
- Toby C Trujillo
- Department of Pharmacy, Boston Medical Center, Northeastern University School of Pharmacy, Boston, Massachusetts 02118, USA
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27
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Choi EK, Koo BK, Kim HS, Cho YM, Kang HJ, Cho YS, Chung WY, Chae IH, Choi DJ, Oh BH, Park YB, Choi YS. Prognostic significance of asymptomatic coronary artery disease in patients with diabetes and need for early revascularization therapy. Diabet Med 2007; 24:1003-11. [PMID: 17509072 DOI: 10.1111/j.1464-5491.2007.02182.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Information on the clinical outcome of patients with diabetes with silent myocardial ischaemia is limited. We compared the clinical and angiographic characteristics, and the clinical outcomes of diabetic patients with asymptomatic or symptomatic coronary artery disease (CAD). METHODS Three hundred and ten consecutive diabetic patients with CAD were divided into two groups according to the presence of angina and followed for a mean of 5 years. Fifty-six asymptomatic patients with a positive stress test and CAD on coronary angiography were compared with 254 symptomatic patients, 167 with unstable angina and 87 with chronic stable angina. RESULTS Although the severity of coronary atherosclerosis was similar in asymptomatic and symptomatic patients, revascularization therapy was performed less frequently in the asymptomatic than the symptomatic patients (26.8 vs. 62.0%; P < 0.001). Asymptomatic patients experienced a similar number of major adverse cardiac events (MACEs; death, non-fatal myocardial infarction, and revascularization; 32 vs. 28%; P = 0.57), but had higher cardiac mortality than symptomatic patients (26 vs. 9%; P < 0.001). However, patients who underwent revascularization therapy at the time of CAD diagnosis in these two groups showed similar MACE and cardiac mortality (20.0 vs. 22.5%, 6.7 vs. 5.3%, respectively; all P > 0.05). CONCLUSIONS This study suggests that diabetic patients with asymptomatic CAD have a higher cardiac mortality risk than those with symptomatic CAD, and that lack of revascularization therapy may be responsible for the poorer survival.
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Affiliation(s)
- E-K Choi
- Seoul National University Hospital and Seoul National University Bundang Hospital, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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28
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Roberts WC, Black HR, Bakris GL, Mason RP, Giles TD, Sulkes DJ. The editor's roundtable: revisiting the role of beta blockers in hypertension. Am J Cardiol 2007; 100:253-67. [PMID: 17631080 DOI: 10.1016/j.amjcard.2007.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 03/28/2007] [Indexed: 11/23/2022]
Affiliation(s)
- William C Roberts
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA.
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29
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&NA;. Appropriate pharmacology should be initiated before, during and following percutaneous coronary intervention in patients with left ventricular dysfunction or heart failure. DRUGS & THERAPY PERSPECTIVES 2007. [DOI: 10.2165/00042310-200723060-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Brandt A, Gulba DC. [Coronary artery disease--relevance of total coronary revascularization on the incidence of malignant arrhythmias]. Herzschrittmacherther Elektrophysiol 2007; 17:211-7. [PMID: 17211752 DOI: 10.1007/s00399-006-0535-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Accepted: 11/17/2006] [Indexed: 10/23/2022]
Abstract
Myocardial ischemia induces redistribution of different ions (H(+), K(+), Na(+), Ca(++)) across the cardiomyocyte membrane, as well as the loss of intracellular ATP content. This results in changes in the electrical properties including shortening of the action potential, appearance of delayed afterpotentials, and a modified refractoriness of the cardiomyocyte. These changes may induce or support malignant cardiac arrhythmias. Supersensitivity of sympathetic denervated myocardium may further support the electrical instability of ischemic myocardium.Virtues of studies indicate that patients with coronary artery disease who develop complex arrhythmias during or after exercise bear a substantially increased risk for sudden cardiac death. Other studies report about arrhythmic stabilization and reduced mortality if patients with reversible myocardial ischemia receive complete revascularization. However, none of these studies is without methodological flaws. Due to the lack of methodologically sound studies in sufficiently large patient cohorts, the question whether complete coronary revascularisation improves the prognosis of patients with coronary artery disease and which strategy (medical, interventional, or surgical) warrants the best outcomes remains open.
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Affiliation(s)
- A Brandt
- Medizinische Klinik I, Schwerpunkte Kardiologie, Angiologie, Pulmologie und Internistische Intensivmedizin, Krankenhaus Düren gGmbH, Roonstrasse 30, 52351 Düren, Germany
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31
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Cruickshank JM. Are we misunderstanding beta-blockers. Int J Cardiol 2007; 120:10-27. [PMID: 17433471 DOI: 10.1016/j.ijcard.2007.01.069] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2006] [Revised: 01/16/2007] [Accepted: 01/30/2007] [Indexed: 12/22/2022]
Abstract
In myocardial ischaemia and heart failure, beta-blockers with intrinsic sympathomimetic activity (ISA) e.g. pindolol, xamoterol, bucindolol, nebivolol, have performed poorly in reducing morbidity and mortality. In both indications beta-1 blockade is the vital active ingredient. Beta-1 blockade (bisoprolol) is now an alternative first-line choice to Ace-inhibition in the treatment of heart failure. The therapeutic role of beta-blockers in hypertension is less well understood, particularly since the new recommendations in the UK from the NICE committee stating that: 1. beta-blockers are no longer preferred as a routine initial therapy, 2. the combination with diuretics is discouraged due to the risk of induced diabetes, and 3. in younger patients first-choice initial therapy should be an ACE-inhibitor. Recent data from the Framingham Heart Study and other epidemiological studies have indicated that the development of diastolic hypertension in younger subjects is closely linked to weight-increase and an increase in peripheral resistance; such subjects have a high adrenergic drive and cardiac output. In contrast, elderly systolic hypertension mostly arises de novo via poor vascular compliance. Thus in younger, probably overweight, hypertensives (including diabetics) first-line beta-blockade has performed well in preventing myocardial infarction (a fact hidden by meta-analyses that do not take age into account). Conversely, in elderly hypertensives first-line beta-blockade (atenolol) has performed poorly in reducing cardiovascular risk (due to partial beta-2 blockade atenolol evokes metabolic disturbance and does not improve vascular compliance, or effectively lower central aortic pressure or reverse left ventricular hypertrophy). Thus beta-blockers like atenolol are ill-equipped for first-line therapy in elderly hypertension. Some beta-blockers, e.g. bisoprolol (up to 10 mg/day is highly beta-1 selective) and nebivolol (beta-2/3 intrinsic sympathomimetic activity), do improve vascular compliance and cause no metabolic disturbance. Beta-blockers as second-line to low-dose diuretics (which, by improving vascular compliance and increasing sympathetic nerve activity, create an optimal environment for beta-blockade) in elderly hypertension (including diabetics) have performed well in reducing cardiovascular events (this combination has the added bonus of reducing the risk of bone fracture by about 30%). Meta-analyses which include studies where it is unclear whether a diuretic or beta-blocker was a first-line therapy will dilute the benefit stemming from first-line diuretic/second-line beta-blockade. Hypertensives (of all ages) with ischaemia are well suited to beta-blockade.
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Affiliation(s)
- J M Cruickshank
- Cambridge University, Long Melford, Suffolk CO10 9DE, United Kingdom.
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Fletcher GF, Bufalino V, Costa F, Goldstein LB, Jones D, Smaha L, Smith SC, Stone N. Efficacy of drug therapy in the secondary prevention of cardiovascular disease and stroke. Am J Cardiol 2007; 99:1E-35E. [PMID: 17378996 DOI: 10.1016/j.amjcard.2007.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Gerald F Fletcher
- Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, Florida 32224, USA.
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Fox K, García MAA, Ardissino D, Buszman P, Camici PG, Crea F, Daly C, de Backer G, Hjemdahl P, López-Sendón J, Morais J, Pepper J, Sechtem U, Simoons M, Thygesen K. [Guidelines on the management of stable angina pectoris. Executive summary]. Rev Esp Cardiol 2007; 59:919-70. [PMID: 17162834 DOI: 10.1157/13092800] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kim Fox
- Sociedad europea de cardiologia
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Lipinski MJ, Vetrovec GW. Medical treatment of patients with heart failure or left ventricular dysfunction undergoing percutaneous coronary intervention. Am J Cardiovasc Drugs 2006; 6:313-25. [PMID: 17083266 DOI: 10.2165/00129784-200606050-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Management of ischemic patients with pre-existing or new-onset left ventricular (LV) dysfunction poses a special challenge in terms of the timing of percutaneous coronary intervention (PCI) and appropriate adjunctive medications to optimize outcome while minimizing risk. In a systematic fashion, this review attempts to provide a management scheme for patients with heart failure or LV dysfunction that present with stable angina, ST-segment elevation myocardial infarction, or unstable angina/non-ST-segment elevation myocardial infarction. By addressing therapeutic approaches to acute or decompensated heart failure and timing of coronary angiography based on severity of ischemia, we provide evidence-based recommendations for medications to initiate before, during, and following PCI.
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Affiliation(s)
- Michael J Lipinski
- Division of Cardiology, Medical College of Virginia Campus of Virginia Commonwealth University, Richmond, Virginia, USA
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36
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Abstract
Ambulatory ECG monitoring (AEM) is the only available method to assess the presence and severity of myocardial ischemia during daily life. Several investigators have shown that the recording systems currently used can detect ischemic changes with similar accuracy as treadmill exercise testing. Ischemic changes on AEM are, however, present in only 40%-60% of patients with coronary artery disease (CAD) and positive exercise tests. For this reason, and because of the high day-to-day variability in daily ischemic changes, AEM cannot be used as a screening tool for detecting CAD or for evaluating severity of ischemia in individual patients. In patients with proven CAD, ischemic changes on AEM are associated with an adverse outcome in patients with stable and unstable ischemic syndromes, and in postmyocardial infarction patients. Suppression of daily ischemia seems to be associated with improved outcome. The mechanism of daily ischemia is not identical to exercise-induced ischemia. In addition to increased demand, which is a major contributor to AEM detected-ischemia, increased coronary tone also seems to play a major role. AEM has been shown to be a useful and reliable tool to assess the efficacy of various antiischemic drugs.
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Affiliation(s)
- D Tzivoni
- Department of Cardiology, Jesselson Heart Center, Shaare Zedek Medical Center, Jerusalem 91031 Israel.
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Marrs JC, Saseen JJ. Chronic Stable Angina: Angiotensin-Converting Enzyme Inhibitor Therapy and/or Calcium-Channel Blocker Therapy—When is it Indicated? J Pharm Technol 2006. [DOI: 10.1177/875512250602200505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To discuss outcomes data assessing the use of angiotensin-converting enzyme (ACE) inhibitors and calcium-channel blockers (CCBs) in the prevention of cardiovascular events in patients with chronic stable angina that have been published since the 2002 American College of Cardiology/American Heart Association (ACC/AHA) updated guidelines for the treatment of chronic stable angina. Data Sources: A MEDLINE search (2002–April 2006) identified 60 primary, review, and meta-analysis articles. The inclusion criteria were: patients with stable coronary artery disease, chronic stable angina, or coronary heart disease; evaluation of long-term therapy with either ACE inhibitor or CCB therapy; prospective, randomized, controlled clinical trials; cardiovascular events as the primary endpoint of the study; and date of publication after the 2002 ACC/AHA guidelines. Study Selection and Data Extraction: All articles identified from the literature search were evaluated, and all clinical trials deemed relevant were included in this review. Six randomized trials met inclusion criteria and evaluated the utility of ACE inhibitor and CCB therapy in reducing cardiovascular events in patients with coronary artery disease and/or chronic stable angina. Data Synthesis: Patient populations, background therapy, and the study endpoints of all 6 trials varied. However, all primary endpoints assessed cardiovascular events. Two of the 3 ACE inhibitor trials demonstrated a significant reduction in the primary endpoint and 1 of the 3 CCB trials demonstrated a significant reduction in the primary endpoint. Conclusions: Newer evidence cumulatively supports the addition of an ACE inhibitor to standard antianginal pharmacotherapy to reduce the risk of cardiovascular events. However, benefit is influenced by severity of illness and use of additional cardiovascular risk reduction pharmacotherapy. The level of supporting evidence for ACE inhibitor therapy in chronic stable angina is higher than that cited in the 2002 ACC/AHA guidelines. Newer evidence evaluating the use of CCBs to prevent cardiovascular events in patients with stable coronary artery disease is controversial and remains consistent with the 2002 guidelines.
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Affiliation(s)
- Joel C Marrs
- JOEL C MARRS PharmD BCPS, at time of writing, Family Medicine Specialty Resident, Department of Family Medicine, University of Colorado at Denver and Health Sciences Center, Denver, CO; now, Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Portland, OR
| | - Joseph J Saseen
- JOSEPH J SASEEN PharmD FCCP BCPS, Associate Professor, Departments of Clinical Pharmacy and Family Medicine, University of Colorado at Denver and Health Sciences Center
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McAlister FA, Fradette M, Graham M, Majumdar SR, Ghali WA, Williams R, Tsuyuki RT, McMeekin J, Grimshaw J, Knudtson ML. A randomized trial to assess the impact of opinion leader endorsed evidence summaries on the use of secondary prevention strategies in patients with coronary artery disease: the ESP-CAD trial protocol [NCT00175240]. Implement Sci 2006; 1:11. [PMID: 16722548 PMCID: PMC1475885 DOI: 10.1186/1748-5908-1-11] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2006] [Accepted: 05/06/2006] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Although numerous therapies have been shown to be beneficial in the prevention of myocardial infarction and/or death in patients with coronary disease, these therapies are under-used and this gap contributes to sub-optimal patient outcomes. To increase the uptake of proven efficacious therapies in patients with coronary disease, we designed a multifaceted quality improvement intervention employing patient-specific reminders delivered at the point-of-care, with one-page treatment guidelines endorsed by local opinion leaders ("Local Opinion Leader Statement"). This trial is designed to evaluate the impact of these Local Opinion Leader Statements on the practices of primary care physicians caring for patients with coronary disease. In order to isolate the effects of the messenger (the local opinion leader) from the message, we will also test an identical quality improvement intervention that is not signed by a local opinion leader ("Unsigned Evidence Statement") in this trial. METHODS Randomized trial testing three different interventions in patients with coronary disease: (1) usual care versus (2) Local Opinion Leader Statement versus (3) Unsigned Evidence Statement. Patients diagnosed with coronary artery disease after cardiac catheterization (but without acute coronary syndromes) will be randomly allocated to one of the three interventions by cluster randomization (at the level of their primary care physician), if they are not on optimal statin therapy at baseline. The primary outcome is the proportion of patients demonstrating improvement in their statin management in the first six months post-catheterization. Secondary outcomes include examinations of the use of ACE inhibitors, anti-platelet agents, beta-blockers, non-statin lipid lowering drugs, and provision of smoking cessation advice in the first six months post-catheterization in the three treatment arms. Although randomization will be clustered at the level of the primary care physician, the design effect is anticipated to be negligible and the unit of analysis will be the patient. DISCUSSION If either the Local Opinion Leader Statement or the Unsigned Evidence Statement improves secondary prevention in patients with coronary disease, they can be easily modified and applied in other communities and for other target conditions.
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Affiliation(s)
- Finlay A McAlister
- The Department of Medicine, University of Alberta, Edmonton, Canada
- The Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Canada
| | - Miriam Fradette
- The Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Canada
| | - Michelle Graham
- The Department of Medicine, University of Alberta, Edmonton, Canada
- The Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Canada
| | - Sumit R Majumdar
- The Department of Medicine, University of Alberta, Edmonton, Canada
- The Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Canada
| | - William A Ghali
- The Department of Medicine, University of Calgary, Calgary, Canada
| | | | - Ross T Tsuyuki
- The Department of Medicine, University of Alberta, Edmonton, Canada
- The Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Canada
| | - James McMeekin
- The Department of Medicine, University of Calgary, Calgary, Canada
| | - Jeremy Grimshaw
- The University of Ottawa Health Research Unit, Ottawa, Canada
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Stone PH. ST-segment analysis in ambulatory ECG (AECG or Holter) monitoring in patients with coronary artery disease: clinical significance and analytic techniques. Ann Noninvasive Electrocardiol 2005; 10:263-78. [PMID: 15842439 PMCID: PMC6932340 DOI: 10.1111/j.1542-474x.2005.10203.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Peter H Stone
- Cardiovascular Division Brigham and Women's Hospital Harvard Medical School, Boston, MA 02115, USA.
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López-Sendón J, Swedberg K, McMurray J, Tamargo J, Maggioni AP, Dargie H, Tendera M, Waagstein F, Kjekshus J, Lechat P, Torp-Pedersen C. Documento de Consenso de Expertos sobre bloqueadores de los receptores ß-adrenérgicos. Rev Esp Cardiol 2005; 58:65-90. [PMID: 15680133 DOI: 10.1157/13070510] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Taniwa T, Miyataka M, Kimura A, Taniguchi M, Hirano Y, Hayashi T, Ishikawa K. Calcium Antagonists for Secondary Prevention of Myocardial Infarction Is There a Need to Shift From Short-Acting to Long-Acting Types? Circ J 2005; 69:1308-14. [PMID: 16247203 DOI: 10.1253/circj.69.1308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although short-acting nifedipine does not prevent myocardial infarction (MI), calcium antagonists with a long half-life may be effective. METHODS AND RESULTS The present study was a retrospective analysis of the incidences of cardiac events among patients with a healed MI treated with 3 times-a-day type nifedipine (half-life 1.8 h; n=617), twice-a-day type nifedipine (half-life 4.0 h; n=527) and those not taking calcium antagonists (n=1,593) from 1986 to 1993, and the incidences of those on once-a-day type calcium antagonists (half-life 11.0 h; n=903) and those not taking calcium antagonists (n=2,788) from 1994 to 2001. Cardiac events included cardiac death and nonfatal recurrent MI. Single and multivariate analyses using the Cox-Hazard model were performed. From 1986 to 1993 cardiac events occurred in 38 patients with 3-times-a-day nifedipine (6.2%, hazard ratio and 95% confidence interval: 1.45 and 0.93-2.27), in 18 patients with twice-a-day nifedipine (3.4%: 0.68 and 0.39-1.20), 57 patients without calcium antagonists (3.6%). Cardiac events also occurred in 11 patients with once-a-day type nifedipine (1.2%: 0.72 and 0.37-1.42) and 48 patients without calcium antagonists (1.7%). Of the once-a-day type calcium antagonists, cardiac events were the lowest (2 patients, 0.6%: 0.32 and 0.08-1.31) in patients with amlodipine (half-life 39.0 h; n=334), which has the longest half-life. None of these drugs were a significant factor in the increase or decrease in the incidence of cardiac events. However, there was a good correlation between the half-life of the calcium antagonist and the hazard ratio for reducing cardiac events. CONCLUSION Although there was a tendency toward a reduction in cardiac events using calcium antagonists with long half-life, none of these drugs could significantly reduce the incidence of cardiac events in patients with a healed MI.
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Affiliation(s)
- Takaaki Taniwa
- Division of Cardiovascular Medicine, Sakai Municipal Hospital, Japan
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42
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Rosendorff C. Calcium antagonists in the treatment of hypertension in patients with ischaemic heart disease. Expert Opin Pharmacother 2003; 4:1535-41. [PMID: 12943483 DOI: 10.1517/14656566.4.9.1535] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Are lives saved or heart attacks prevented by antihypertensive therapy, as a result of blood pressure reduction alone, or because of other properties of the antihypertensive medications which are independent of blood pressure lowering? Long-acting calcium antagonists seem to be as effective as thiazide diuretics and angiotensin-converting enzyme (ACE) inhibitors in preventing all-cause mortality and stroke in patients with hypertension, but are probably inferior to ACE inhibitors in preventing coronary artery disease. In patients with symptomatic coronary artery disease, calcium antagonists are generally as effective as beta-blockers in relieving angina and improving exercise time-to-onset of angina or ischaemia. Unstable angina or myocardial infarction require treatment with a beta-blocker, with an ACE inhibitor added when necessary for blood pressure control or if there is significant left ventricular (LV) dysfunction. If beta-blockers are contraindicated and if there is no LV dysfunction, a non-dihydropyridine calcium antagonist can be substituted.
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Affiliation(s)
- Clive Rosendorff
- The Mount Sinai School of Medicine and the Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA.
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Abstract
Coronary artery disease remains one of the principal causes of disability worldwide. Its most common manifestation is angina pectoris. Angina occurs due to an imbalance between myocardial oxygen demand and supply; it is classically precipitated by physical activity, emotion, eating, or cold weather. It is defined as stable when its frequency, severity, duration, time of appearance, and precipitating factors remain unchanged for 60 days. Treatment of patients with stable angina targets a number of factors that underlie its pathophysiology: aspirin as an antiplatelet agent, b-blockade to reduce myocardial oxygen demand, and additional antianginal drugs when symptoms are incompletely controlled by b-blockers alone. Furthermore, aggressive treatment of risk factors for the development of coronary artery disease confers a significant mortality benefit. Unstable angina is defined as symptoms developing at rest, on minimal exertion, and of increasing severity, duration, or frequency. It is associated with significant mortality; consequently, early assessment and intervention is essential to prevent worsening ischemia. Treatment includes close in-patient monitoring, administration of antiplatelet and antithrombotic drugs, and a combination of b-blockers, calcium antagonists, and intravenous nitrates where appropriate. Coronary revascularization should be considered in high-risk patients, and when conservative management strategies fail.
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Affiliation(s)
- Brian Noronha
- Department of Cardiology, GKT School of Medicine, Bessemer Road, London SE5 9PJ, UK
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44
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Rosendorff C. Managing the hypertensive patient with ischemic heart disease. Curr Hypertens Rep 2002; 4:350-7. [PMID: 12217252 DOI: 10.1007/s11906-002-0063-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Thiazide diuretics, b-blockers, calcium channel blockers, and angiotensin converting enzyme (ACE) inhibitors are all superior to placebo for the primary prevention of coronary events in patients with hypertension. Recent studies have shown that ACE inhibitors are better than other antihypertensive agents in lowering overall cardiovascular morbidity and mortality, especially stroke. Blood pressure should be aggressively lowered (to < 140/90 mm Hg), especially in diabetic patients (to < 130/80 mm Hg), but care should be exercised in lowering the diastolic blood pressure below 65 mm Hg in patients with significant occlusive coronary artery disease. Hypertension in patients with stable angina should be treated with a b-blocker (alternatively a calcium channel blocker) together with an ACE inhibitor. Patients with hypertension and acute coronary syndrome (unstable angina or myocardial infarction) should be treated with a b-blocker, and with an ACE inhibitor if there is left ventricular dysfunction. A thiazide diuretic and/or a dihydropyridine calcium channel blocker could be added for blood pressure control. Calcium channel blockers should be avoided if there is significant left ventricular dysfunction.
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Affiliation(s)
- Clive Rosendorff
- Department of Medicine, Mount Sinai School of Medicine and the Bronx VAMC, NY 10468, USA.
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45
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Deanfield JE, Detry JM, Sellier P, Lichtlen PR, Thaulow E, Bultas J, Brennan C, Young ST, Beckerman B. Medical treatment of myocardial ischemia in coronary artery disease: effect of drug regime and irregular dosing in the CAPE II trial. J Am Coll Cardiol 2002; 40:917-25. [PMID: 12225716 DOI: 10.1016/s0735-1097(02)02050-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The Circadian Anti-ischemia Program in Europe (CAPE II) compared the efficacy of amlodipine and diltiazem (Adizem XL) and the combination of amlodipine/atenolol and diltiazem (Adizem XL)/isosorbide 5-mononitrate on exercise and ambulatory myocardial ischemia during regular therapy and after omission of medication. BACKGROUND The optimal medical therapy for ischemia suppression and the impact of irregular dosing using agents with different pharmacologic properties has not been established in patients with coronary disease. METHODS Patients with > or = 4 ischemic episodes or > or = 20 min of ST segment depression on 72-h electrocardiogram were randomized to amlodipine 10 mg once daily or diltiazem (Adizem XL) 300 mg once daily in a 14-week double-blind randomized multicountry study. In the second phase, atenolol 100 mg was added to amlodipine and isosorbide 5-mononitrate 100 mg to diltiazem (Adizem XL). Ambulatory monitoring (72 h) and exercise testing were repeated after both phases, on treatment and after a 24-h drug-free interval. RESULTS Both monotherapy with amlodipine and diltiazem (Adizem XL) were effective on symptoms and ambulatory and exercise ischemia. Combination therapy reduced ischemia further, with amlodipine/atenolol superior to diltiazem (Adizem XL)/isosorbide 5-mononitrate. Amlodipine/atenolol was significantly superior during the drug-free interval with maintenance of ischemia reduction. CONCLUSIONS Amlodipine, with its intrinsically long half-life alone or together with beta-blocker, is likely to produce superior ischemia reduction in clinical practice when patients frequently forget to take medication or dose irregularly.
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Affiliation(s)
- John E Deanfield
- Vascular Physiology Unit, Great Ormond Street Hospital for Children, London, United Kingdom.
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46
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Deedwania PC, Stone PH. Ambulatory electrocardiographic monitoring for myocardial ischemia. Curr Probl Cardiol 2001; 26:680-727. [PMID: 11677468 DOI: 10.1053/cd.2001.v26.01026101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- P C Deedwania
- UCSF School of Medicine, San Francisco, California, USA
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47
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Abstract
Chronic stable angina is a common condition with a prognosis that is less benign than is generally appreciated. The optimal treatment strategy of this disorder is unclear, and few anti-ischaemic agents have been rigorously tested in prospectively randomised mortality studies. The evidence base for the anti-ischaemic therapy of chronic angina draws upon data 'borrowed' from studies in acute coronary syndromes, and from studies in chronic angina using surrogate endpoints such as ambulatory silent ischaemia. Such evidence leads us to believe that anti-ischaemic therapy with beta-blockers offers a mortality benefit in chronic angina. In contrast, the mortality benefit of lipid lowering therapy and antiplatelet agents is well proven. Angioplasty offers no mortality benefit in the treatment of chronic angina, although it is more effective than medical therapy alone for the relief of symptoms. In a few patients with high order proximal coronary disease, coronary bypass surgery offers a distinct mortality advantage compared with medical treatment alone. Most patients, however, do not warrant such an approach, and only require surgery for when they remain symptomatic despite adequate medical therapy. Alternative strategies such as cardiac transplantation, transmyocardial laser revascularisation and spinal cord stimulation are now accepted in a subgroup of patients for the treatment of chronic angina refractory to standard therapy.
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Affiliation(s)
- A D Staniforth
- Department of Cardiology, St Bartholomew's Hospital, West Smithfield, London, England.
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&NA;. Silent myocardial ischaemia: quietly contributing to cardiovascular morbidity and mortality in the elderly. DRUGS & THERAPY PERSPECTIVES 2001. [DOI: 10.2165/00042310-200117150-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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49
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Abstract
Coronary artery disease (CAD) is a leading cause of death and disability in the elderly. Several recent studies have shown that silent myocardial ischaemia (SMI) is a common manifestation of CAD, especially in the elderly. As many as 40% of elderly patients with no prior history of CAD may have underlying asymptomatic disease and up to 50% of elderly patients with known CAD might have evidence of SMI. The results of studies in elderly patients with CAD have also shown that SMI might exist despite antianginal therapy that is considered adequate for symptom control. In order to diagnose such residual SMI, the clinician would need to perform 24- to 48-hour Holter monitoring in the ambulatory setting while the patient is performing routine daily activities. Although a number of anti-ischaemic drugs have been evaluated for the treatment of SMI, available data suggest that beta-blocker given alone or in combination with a nitrate compound or calcium antagonist provides the best therapeutic choice. The long term benefit of SMI suppression in elderly patients has not been established. Future studies need to evaluate the clinical benefits of therapy given for SMI in the elderly.
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Affiliation(s)
- P C Deedwania
- Department of Medicine, VA Central California Healthcare System/UCSF Program, Fresno, California 93703,USA.
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50
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Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM, Grunwald MA, Levy D, Lytle BW, O'Rourke RA, Schafer WP, Williams SV, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A, Russell RO, Ryan TJ, Smith SC. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 1999; 33:2092-197. [PMID: 10362225 DOI: 10.1016/s0735-1097(99)00150-3] [Citation(s) in RCA: 367] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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