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Jarjour M, Ducharme A. Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines? Drugs Context 2023; 12:2023-5-6. [PMID: 38021409 PMCID: PMC10664772 DOI: 10.7573/dic.2023-5-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.
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Affiliation(s)
- Marilyne Jarjour
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
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2
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Optimization of pharmacotherapies for ambulatory patients with heart failure and reduced ejection fraction is associated with improved outcomes. Int J Cardiol 2023; 370:300-308. [PMID: 36174819 DOI: 10.1016/j.ijcard.2022.09.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND In heart failure, specific target doses for each drug are recommended, but some patients receive suboptimal dosing, others are undertreated or remain chronically in a titration phase, despite having no apparent contraindication or intolerance. We assessed the association of different levels of adherence to guidelines with outcomes in patients with heart failure and reduced ejection fraction (HFrEF). METHODS Medical records of patients with HFrEF followed at our heart failure (HF) clinic for at least 6 months (n = 511) were reviewed and patients categorized as: 1) optimized (25.4%); 2) in-titration (29.0%); 3) undertreated (32.7%); and 4) intolerant/contraindicated (12.9%). Risk of mortality or HF events (hospitalization, emergency visit or ambulatory administration of intravenous diuretics) within one year was assessed using Cox regression models and Kaplan-Meier curves. RESULTS Compared to optimized patients, those intolerant (HR: 4.60 [95%CI: 2.23-9.48]; p < 0.0001) had the highest risk of outcomes, followed by those undertreated (3.45 [1.78-6.67]; p = 0.0002) and in-titration (1.99 [0.97-4.06]; p = 0.0588). Overall predictors of outcomes included loop diuretics' use (4.54 [2.39-8.60]), undertreatment (2.38 [1.22-4.67]), intolerance/ contraindication to triple therapy (3.08 [1.47-6.42]), peripheral vascular disease (2.13 [1.29-3.50]) and NYHA class III-IV (1.89 [1.25-2.85]); all p < 0.05. CONCLUSION Level of adherence to guidelines is associated with outcomes, with intolerant/contraindicated patients having the worst prognosis and those undertreated and in-titration at intermediate risk compared to those optimized. Up-titration of therapy should be attempted whenever possible, considering patients' limitations, to potentially improve outcomes.
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3
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Milinković I, Polovina M, Coats AJS, Rosano GMC, Seferović PM. Medical Treatment of Heart Failure with Reduced Ejection Fraction in the Elderly. Card Fail Rev 2022; 8:e17. [PMID: 35601008 PMCID: PMC9115638 DOI: 10.15420/cfr.2021.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/26/2021] [Indexed: 11/24/2022] Open
Abstract
The aging population, higher burden of predisposing conditions and comorbidities along with improvements in therapy all contribute to the growing prevalence of heart failure (HF). Although the majority of trials have not demonstrated age-dependent heterogeneity in the efficacy or safety of medical treatment for HF, the latest trials demonstrate that older participants are less likely to receive established drug therapies for HF with reduced ejection fraction. There remains reluctance in real-world clinical practice to prescribe and up-titrate these medications in older people, possibly because of (mis)understanding about lower tolerance and greater propensity for developing adverse drug reactions. This is compounded by difficulties in the management of multiple medications, patient preferences and other non-medical considerations. Future research should provide a more granular analysis on how to approach medical and device therapies in elderly patients, with consideration of biological differences, difficulties in care delivery and issues relevant to patients’ values and perspectives. A variety of approaches are needed, with the central principle being to ‘add years to life – and life to years’. These include broader representation of elderly HF patients in clinical trials, improved education of healthcare professionals, wider provision of specialised centres for multidisciplinary HF management and stronger implementation of HF medical treatment in vulnerable patient groups.
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Affiliation(s)
- Ivan Milinković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | | | | | - Petar M Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Serbian Academy of Sciences and Arts, Belgrade, Serbia
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4
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Stolfo D, Lund LH, Becher PM, Orsini N, Thorvaldsen T, Benson L, Hage C, Dahlström U, Sinagra G, Savarese G. Use of evidence‐based therapy in heart failure with reduced ejection fraction across age strata. Eur J Heart Fail 2022; 24:1047-1062. [PMID: 35278267 PMCID: PMC9546348 DOI: 10.1002/ejhf.2483] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/05/2022] [Accepted: 03/10/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Davide Stolfo
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Cardiothoracovascular Department and University of Trieste Trieste Italy
| | - Lars H Lund
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Peter Moritz Becher
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center of Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck Germany
| | - Nicola Orsini
- Department of Global Public Health Karolinska Institutet Stockholm Sweden
| | - Tonje Thorvaldsen
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Lina Benson
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
| | - Camilla Hage
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences Linköping University Linköping Sweden
| | - Gianfranco Sinagra
- Cardiothoracovascular Department and University of Trieste Trieste Italy
| | - Gianluigi Savarese
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
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5
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Kobayashi M, Voors AA, Ouwerkerk W, Duarte K, Girerd N, Rossignol P, Metra M, Lang CC, Ng LL, Filippatos G, Dickstein K, van Veldhuisen DJ, Zannad F, Ferreira JP. Perceived risk profile and treatment optimization in heart failure: an analysis from BIOlogy Study to TAilored Treatment in chronic heart failure. Clin Cardiol 2021; 44:780-788. [PMID: 33960439 PMCID: PMC8207977 DOI: 10.1002/clc.23576] [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] [Received: 12/08/2020] [Revised: 01/07/2021] [Accepted: 02/08/2021] [Indexed: 12/21/2022] Open
Abstract
Background Achieving target doses of angiotensin‐converting‐enzyme inhibitor/angiotensin‐receptor blockers (ACEi/ARB) and beta‐blockers in heart failure with reduced ejection fraction (HFrEF) is often underperformed. In BIOlogy Study to TAilored Treatment in chronic heart failure (BIOSTAT‐CHF) study, many patients were not up‐titrated for which no clear reason was reported. Therefore, we hypothesized that perceived‐risk profile might influence treatment optimization. Methods We studied 2100 patients with HFrEF (LVEF≤40%) to compare the clinical characteristics and adverse events associated with treatment up‐titration (after a 3‐month titration protocol) between; a) patients not reaching target doses for unclear reason; b) patients not reaching target doses due to symptoms and/or side effects; c) patients reaching target doses. Results For ACEi/ARB, (a), (b) and (c) was observed in 51.3%, 25.9% and 22.7% of patients, respectively. For beta‐blockers, (a), (b) and (c) was observed in 67.5%, 20.2% and 12.3% of patients, respectively. By multinomial logistic regression analysis for ACEi/ARB, patients in group (a) and (b) had lower blood pressure and poorer renal function, and patients in group (a) were older and had lower ejection fraction. For beta‐blockers, patients in group (a) and (b) had more severe congestion and lower heart rate. At 9 months, adverse events (i.e., hypotension, bradycardia, renal impairment, and hyperkalemia) occurred similarly among the three groups. Conclusions Patients in whom clinicians did not give a reason why up‐titration was missed were older and had more co‐morbidities. Patients in whom up‐titration was achieved did not have excess adverse events. However, from these observational findings, the pattern of subsequent adverse events among patients in whom up‐titration was missed cannot be determined.
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Affiliation(s)
- Masatake Kobayashi
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Hospital Drive, Singapore.,Department of Dermatology, Amsterdam UMC, Amsterdam Infection & Immunity Institute, University of Amsterdam, Amsterdam, Netherlands
| | - Kevin Duarte
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Marco Metra
- Cardiology. University and Civil hospitals of Brescia, Brescia, Italy
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | | | - Kenneth Dickstein
- Department of Internal Medicine, University of Bergen, Bergen, Norway.,Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
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6
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Liang B, Zhao YX, Zhang XX, Liao HL, Gu N. Reappraisal on pharmacological and mechanical treatments of heart failure. Cardiovasc Diabetol 2020; 19:55. [PMID: 32375806 PMCID: PMC7202267 DOI: 10.1186/s12933-020-01024-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/25/2020] [Indexed: 02/07/2023] Open
Abstract
Heart failure (HF) is a highly frequent disorder with considerable morbidity, hospitalization, and mortality; thus, it invariably places pressure on clinical and public health systems in the modern world. There have been notable advances in the definition, diagnosis, and treatment of HF, and newly developed agents and devices have been widely adopted in clinical practice. Here, this review first summarizes the current emerging therapeutic agents, including pharmacotherapy, device-based therapy, and the treatment of some common comorbidities, to improve the prognosis of HF patients. Then, we discuss and point out the commonalities and areas for improvement in current clinical studies of HF. Finally, we highlight the gaps in HF research. We are looking forward to a bright future with reduced morbidity and mortality from HF.
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Affiliation(s)
- Bo Liang
- Nanjing University of Chinese Medicine, Nanjing, China
| | - Yu-Xiu Zhao
- Hospital (T.C.M.) Affiliated to Southwest Medical University, Luzhou, China
| | | | - Hui-Ling Liao
- Hospital (T.C.M.) Affiliated to Southwest Medical University, Luzhou, China
- College of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou, China
| | - Ning Gu
- Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing, China.
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7
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Mordi IR, Ouwerkerk W, Anker SD, Cleland JG, Dickstein K, Metra M, Ng LL, Samani NJ, van Veldhuisen DJ, Zannad F, Voors AA, Lang CC. Heart failure treatment up-titration and outcome and age: an analysis of BIOSTAT-CHF. Eur J Heart Fail 2020; 23:436-444. [PMID: 32216000 DOI: 10.1002/ejhf.1799] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/22/2020] [Accepted: 02/24/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS Several studies have shown that older patients with heart failure with reduced ejection fraction (HFrEF) are undertreated. The aim of this study was to evaluate the association of up-titration of angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) and beta-blockers on outcome across the age spectrum in HFrEF patients. METHODS AND RESULTS We analysed HFrEF patients on sub-optimal doses of ACEI/ARB and/or beta-blockers from the BIOSTAT-CHF study stratified by age. Patients underwent a 3-month up-titration period. We used inverse probability weighting to adjust for the likelihood of successful up-titration to determine the association of achieved dose with mortality and/or heart failure hospitalisation, testing for an interaction with age. Over a median follow-up of 21 months in 1720 HFrEF patients (76.5% male, mean age 67 years), the primary outcome occurred in 558 patients. Increased percentage of target dose of ACEI/ARB and beta-blocker achieved at 3 months were both significantly associated with reduced incidence of the primary outcome, [ACEI-ARB: hazard ratio (HR) per 12.5% increase in dose: 0.92, 95% confidence interval (CI) 0.91-0.94, P < 0.001; beta-blocker: HR 0.98, 95% CI 0.95-1.00, P = 0.046], with a significant interaction with age seen for beta-blockers but not ACEI/ARB (P = 0.034 and P = 0.22, respectively). CONCLUSIONS Achieving higher doses of ACEI/ARB was associated with improved outcome regardless of age. However, achieving higher doses of beta-blockers was only associated with improved outcome in younger, but not in older patients.
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Affiliation(s)
- Ify R Mordi
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore.,Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection & Immunity Institute, Amsterdam, The Netherlands
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
| | - John G Cleland
- National Heart & Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, London, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway.,Stavanger University Hospital, Stavanger, Norway
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Dirk J van Veldhuisen
- University Medical Center Groningen, Department of Cardiology, University of Groningen, Groningen, The Netherlands
| | - Faiez Zannad
- Inserm CIC-P 1433, Université de Lorraine, CHRU de Nancy, FCRIN INI-CRCT, Nancy, France
| | - Adriaan A Voors
- University Medical Center Groningen, Department of Cardiology, University of Groningen, Groningen, The Netherlands
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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8
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Fellahi JL, Godier A, Benchetrit D, Berthier F, Besch G, Bochaton T, Bonnefoy-Cudraz E, Coriat P, Gayat E, Hong A, Jenck S, Le Gall A, Longrois D, Martin AC, Pili-Floury S, Piriou V, Provenchère S, Rozec B, Samain E, Schweizer R, Billard V. Perioperative management of patients with coronary artery disease undergoing non-cardiac surgery: Summary from the French Society of Anaesthesia and Intensive Care Medicine 2017 convention. Anaesth Crit Care Pain Med 2018; 37:367-374. [PMID: 29567130 DOI: 10.1016/j.accpm.2018.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/09/2018] [Accepted: 02/26/2018] [Indexed: 12/19/2022]
Abstract
This review summarises the specific stakes of preoperative, intraoperative, and postoperative periods of patients with coronary artery disease undergoing non-cardiac surgery. All practitioners involved in the perioperative management of such high cardiac risk patients should be aware of the modern concepts expected to decrease major adverse cardiac events and improve short- and long-term outcomes. A multidisciplinary approach via a functional heart team including anaesthesiologists, cardiologists and surgeons must be encouraged. Rational and algorithm-guided management of those patients should be known and implemented from preoperative to postoperative period.
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Affiliation(s)
- Jean-Luc Fellahi
- Department of anaesthesia and intensive care, Louis-Pradel hospital, hospices civils de Lyon, 59, boulevard Pinel, 69394 Lyon cedex 03, France.
| | - Anne Godier
- Department of anaesthesia and intensive care, fondation Adolphe-de-Rothschild, 75019 Paris, France
| | - Deborah Benchetrit
- Department of anaesthesia and intensive care, Pitié-Salpêtrière university hospital, Paris, France
| | - Francis Berthier
- Department of anaesthesia and intensive care, Besançon university hospital, Besançon, France
| | - Guillaume Besch
- Department of anaesthesia and intensive care, Besançon university hospital, Besançon, France
| | - Thomas Bochaton
- Intensive care and cardiological emergencies, Louis-Pradel hospital, hospices civils de Lyon, Lyon, France
| | - Eric Bonnefoy-Cudraz
- Intensive care and cardiological emergencies, Louis-Pradel hospital, hospices civils de Lyon, Lyon, France
| | - Pierre Coriat
- Department of anaesthesia and intensive care, Pitié-Salpêtrière university hospital, Paris, France
| | - Etienne Gayat
- Department of anaesthesia ans intensive care, Saint-Louis-Lariboisière-Fernand-Widal university hospitals, Paris, France
| | - Alex Hong
- Department of anaesthesia ans intensive care, Saint-Louis-Lariboisière-Fernand-Widal university hospitals, Paris, France
| | - Sophie Jenck
- Intensive care and cardiological emergencies, Louis-Pradel hospital, hospices civils de Lyon, Lyon, France
| | - Arthur Le Gall
- Department of anaesthesia ans intensive care, Saint-Louis-Lariboisière-Fernand-Widal university hospitals, Paris, France
| | - Dan Longrois
- Department of anaesthesia and intensive care, Bichat-Claude-Bernard hospital, Paris, France
| | | | - Sébastien Pili-Floury
- Department of anaesthesia and intensive care, Besançon university hospital, Besançon, France
| | - Vincent Piriou
- Department of anaesthesia and intensive care, hospices civils de Lyon, Lyon-sud hospital, Lyon, France
| | - Sophie Provenchère
- Department of anaesthesia and intensive care, Bichat-Claude-Bernard hospital, Paris, France
| | - Bertrand Rozec
- Department of anaesthesia and intensive care, Nantes university hospital, Nantes, France
| | - Emmanuel Samain
- Department of anaesthesia and intensive care, Besançon university hospital, Besançon, France
| | - Rémi Schweizer
- Department of anaesthesia and intensive care, Louis-Pradel hospital, hospices civils de Lyon, 59, boulevard Pinel, 69394 Lyon cedex 03, France
| | - Valérie Billard
- Department of anaesthesia, institut Gustave-Roussy, Villejuif, France
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9
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Li Z, Liu B, Zhao D, Wang B, Liu Y, Zhang Y, Tian F, Li B. Protective effects of Nebivolol against interleukin-1β (IL-1β)-induced type II collagen destruction mediated by matrix metalloproteinase-13 (MMP-13). Cell Stress Chaperones 2017; 22:767-774. [PMID: 28512729 PMCID: PMC5655365 DOI: 10.1007/s12192-017-0805-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 04/12/2017] [Accepted: 05/04/2017] [Indexed: 01/18/2023] Open
Abstract
The pathological progression of osteoarthritis (OA) involves degradation of articular cartilage matrix. Type II collagen is the main component of cartilage matrix, which is degraded by pro-inflammatory cytokines such as IL-1β mediated by MMP-13. Nebivolol, a licensed drug used for the treatment of hypertension in clinics, displays its anti-inflammatory capacity in various conditions. However, whether Nebivolol has a protective effect on cartilage matrix degradation has not been reported before. In this study, we investigated the effects of Nebivolol on regulating the expression of MMP-13 and degradation of type II collagen. Our results indicate that Nebivolol alleviated the increase in gene expression, protein expression, and activity of MMP-13 induced by IL-1β. Importantly, IL-1β strikingly reduced the levels of type II collagen in cell culture supernatants, which was reversed by treatment with Nebivolol in a dose-dependent manner. Mechanistically, Nebivolol was found to alleviate the increased levels of phosphorylated IκBα and reduced levels of total IκBα induced by IL-1β, which subsequently mitigated p65 nuclear translocation and the transcriptional activity of NF-κB. Furthermore, our results indicated that IL-1β treatment resulted in a significant increase in expression of the transcriptional factor interferon regulatory factor-1 (IRF-1) at both the mRNA and protein levels, which was significantly ameliorated by treatment with Nebivolol. The combination of these findings suggests that Nebivolol can potentially be applied in human OA treatment.
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Affiliation(s)
- Zhigang Li
- Department of Biomedical Engineering, Faculty of Electronic Information and Electrical Engineering, Dalian University of Technology, Dalian, Liaoning, People's Republic of China
- Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, No. 6 Jiefang Street, Dalian, Liaoning, 116001, People's Republic of China
| | - Baoyi Liu
- Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, No. 6 Jiefang Street, Dalian, Liaoning, 116001, People's Republic of China
| | - Dewei Zhao
- Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, No. 6 Jiefang Street, Dalian, Liaoning, 116001, People's Republic of China.
| | - BenJie Wang
- Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, No. 6 Jiefang Street, Dalian, Liaoning, 116001, People's Republic of China
| | - Yupeng Liu
- Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, No. 6 Jiefang Street, Dalian, Liaoning, 116001, People's Republic of China
| | - Yao Zhang
- Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, No. 6 Jiefang Street, Dalian, Liaoning, 116001, People's Republic of China
| | - Fengde Tian
- Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, No. 6 Jiefang Street, Dalian, Liaoning, 116001, People's Republic of China
| | - Borui Li
- Department of Orthopaedics, Affiliated Zhongshan Hospital of Dalian University, No. 6 Jiefang Street, Dalian, Liaoning, 116001, People's Republic of China
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10
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Kotecha D, Flather MD, Altman DG, Holmes J, Rosano G, Wikstrand J, Packer M, Coats AJS, Manzano L, Böhm M, van Veldhuisen DJ, Andersson B, Wedel H, von Lueder TG, Rigby AS, Hjalmarson Å, Kjekshus J, Cleland JGF. Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure. J Am Coll Cardiol 2017; 69:2885-2896. [PMID: 28467883 DOI: 10.1016/j.jacc.2017.04.001] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/31/2017] [Accepted: 04/02/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The relationship between mortality and heart rate remains unclear for patients with heart failure with reduced ejection fraction in either sinus rhythm or atrial fibrillation (AF). OBJECTIVES This analysis explored the prognostic importance of heart rate in patients with heart failure with reduced ejection fraction in randomized controlled trials comparing beta-blockers and placebo. METHODS The Beta-Blockers in Heart Failure Collaborative Group performed a meta-analysis of harmonized individual patient data from 11 double-blind randomized controlled trials. The primary outcome was all-cause mortality, analyzed with Cox proportional hazard ratios (HR) modeling heart rate measured at baseline and approximately 6 months post-randomization. RESULTS A higher heart rate at baseline was associated with greater all-cause mortality for patients in sinus rhythm (n = 14,166; adjusted HR: 1.11 per 10 beats/min; 95% confidence interval [CI]: 1.07 to 1.15; p < 0.0001) but not in AF (n = 3,034; HR: 1.03 per 10 beats/min; 95% CI: 0.97 to 1.08; p = 0.38). Beta-blockers reduced ventricular rate by 12 beats/min in both sinus rhythm and AF. Mortality was lower for patients in sinus rhythm randomized to beta-blockers (HR: 0.73 vs. placebo; 95% CI: 0.67 to 0.79; p < 0.001), regardless of baseline heart rate (interaction p = 0.35). Beta-blockers had no effect on mortality in patients with AF (HR: 0.96, 95% CI: 0.81 to 1.12; p = 0.58) at any heart rate (interaction p = 0.48). A lower achieved resting heart rate, irrespective of treatment, was associated with better prognosis only for patients in sinus rhythm (HR: 1.16 per 10 beats/min increase, 95% CI: 1.11 to 1.22; p < 0.0001). CONCLUSIONS Regardless of pre-treatment heart rate, beta-blockers reduce mortality in patients with heart failure with reduced ejection fraction in sinus rhythm. Achieving a lower heart rate is associated with better prognosis, but only for those in sinus rhythm.
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Affiliation(s)
- Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, United Kingdom; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Marcus D Flather
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy; Cardiovascular and Cell Science Institute, St. George's University of London, London, United Kingdom
| | - John Wikstrand
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Andrew J S Coats
- Monash University, Melbourne, Victoria, Australia; University of Warwick, Warwick, United Kingdom
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska University Hospital and Gothenburg University, Gothenburg, Sweden
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas G von Lueder
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Alan S Rigby
- Academic Cardiology, Castle Hill Hospital, Kingston upon Hull, United Kingdom
| | - Åke Hjalmarson
- Department of Cardiology, Sahlgrenska University Hospital and Gothenburg University, Gothenburg, Sweden
| | - John Kjekshus
- Rikshospitalet University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, United Kingdom.
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11
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Cohen-Solal A, Jacobson AF, Piña IL. Beta blocker dose and markers of sympathetic activation in heart failure patients: interrelationships and prognostic significance. ESC Heart Fail 2017; 4:499-506. [PMID: 29154422 PMCID: PMC5695165 DOI: 10.1002/ehf2.12153] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/13/2017] [Accepted: 02/17/2017] [Indexed: 01/08/2023] Open
Abstract
Aims Extent of cardiac sympathetic activation can be estimated from physiological parameters, blood biomarkers, and imaging findings. This study examined the prognostic value of three markers of sympathetic activity and their relationship to beta blocker dose in heart failure patients. Methods and results A post hoc analysis of 858 heart failure subjects in the ADMIRE‐HF trial was performed. Variables related to sympathetic activity were plasma norepinephrine, baseline heart rate, the heart to mediastinum (H/M) ratio of 123I‐mIBG uptake, and beta blocker dose. Univariate and multivariate analyses for occurrence of mortality (all‐cause and cardiac) and arrhythmic events were performed. Beta blocker dose was significantly related to age, heart rate, b‐type natriuretic peptide (negatively), body mass index, body weight and plasma norepinephrine. Univariate predictors of all‐cause and cardiac mortality were baseline heart rate (χ2 = 4.5, P = 0.029 and χ2 = 5 .2, P = 0.022, respectively), plasma norepinephrine level (χ2 = 8.9, P = 0.0006 and χ2 = 8.6, P = 0.003, respectively), and H/M (χ = 22.4, P < 0.0001 and χ2 = 17.8, P < 0.0001, respectively). In multivariate analyses, carvedilol‐equivalent dose (P = 0.017), plasma norepinephrine (P = 0.002), and H/M (P = 0.0001) were significant predictors of all‐cause mortality. In separate analyses using multiple measurements of heart rate, mean heart rate >67 b.p.m. was associated with significantly higher cardiac mortality. Conclusions Higher beta blocker dose was associated with lower mortality, but of the variables associated with sympathetic activity examined, cardiac 123I‐mIBG uptake was the most powerful prognostic marker in heart failure patients. Elevated heart rate was associated with greater risk for cardiac death.
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Affiliation(s)
- Alain Cohen-Solal
- UMR-S 942, Paris Diderot University, FIRE DHU, Lariboisiere Hospital, Assistance Publique - Hopitaux de Paris, Paris, France
| | | | - Ileana L Piña
- Division of Cardiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
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12
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Ouwerkerk W, Voors A, Anker S, Cleland J, Dickstein K, Filippatos G, van der Harst P, Hillege H, Lang C, ter Maaten J, Ng L, Ponikowski P, Samani N, van Veldhuisen D, Zannad F, Metra M, Zwinderman A. Determinants and clinical outcome of uptitration of ACE-inhibitors and beta-blockers in patients with heart failure: a prospective European study. Eur Heart J 2017; 38:1883-1890. [DOI: 10.1093/eurheartj/ehx026] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 01/10/2017] [Indexed: 11/13/2022] Open
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13
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Vorilhon C, Jean F, Mulliez A, Clerfond G, Pereira B, Sapin V, Souteyrand G, Citron B, Motreff P, Lusson JR, Eschalier R. Optimized management of heart failure patients aged 80 years or more improves outcomes versus usual care: The HF80 randomized trial. Arch Cardiovasc Dis 2016; 109:667-678. [PMID: 27825591 DOI: 10.1016/j.acvd.2016.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 01/20/2016] [Accepted: 02/04/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND The prevalence and incidence of heart failure (HF) in elderly patients are increasing worldwide. Management of HF with reduced ejection fraction (HF-REF) in patients aged 80 years or more follows international guidelines, despite the lack of a dedicated study in this frail population. AIMS To determine whether optimized management of HF-REF in patients aged 80 years or more can improve quality of life at 6 months. METHODS Patients aged 80 years or more hospitalized for acute HF-REF were randomized prospectively into an optimized group or a control group (usual care). All patients benefitted from the same in-hospital management. Optimized group patients were also managed at 3, 6 and 9 weeks, and 3, 6, 9 and 12 months after initial hospitalization, to optimize HF-REF treatment. The primary endpoint was quality of life at 6 months. RESULTS The trial was stopped prematurely, according to prespecified rules and an independent data monitoring board, after 34 patients were included (n=17 in each group). There was no difference in quality of life at baseline and at 6 months between the two groups (P=0.14 and 0.64, respectively), although a significant improvement was observed between baseline and 6 months in the optimized group compared with the control group: -20.2±25.2 (P=0.01) versus -9.9±19.0 (P=0.19). Mortality at 12 months was lower in the optimized group (17.7% vs 47.1%; P=0.03). There was no increase in acute renal failure, hyperkalaemia or falls in the optimized group (P=0.49, 1 and 1, respectively). CONCLUSIONS Optimizing the management of HF-REF in patients aged 80 years or more, according to the modalities of the HF80 study, seems to be both effective and safe.
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Affiliation(s)
- Charles Vorilhon
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France; Clermont Université, ISIT-CaVITI, BP 10448, Clermont-Ferrand, France
| | - Frédéric Jean
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélien Mulliez
- Biostatistics Unit (Clinical Research and Innovation Direction), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Guillaume Clerfond
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France; Clermont Université, ISIT-CaVITI, BP 10448, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit (Clinical Research and Innovation Direction), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Vincent Sapin
- Department of Biochemistry, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Géraud Souteyrand
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France; Clermont Université, ISIT-CaVITI, BP 10448, Clermont-Ferrand, France
| | - Bernard Citron
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Pascal Motreff
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France; Clermont Université, ISIT-CaVITI, BP 10448, Clermont-Ferrand, France
| | - Jean-René Lusson
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France; Clermont Université, ISIT-CaVITI, BP 10448, Clermont-Ferrand, France
| | - Romain Eschalier
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France; Clermont Université, ISIT-CaVITI, BP 10448, Clermont-Ferrand, France; INI-CRCT F-CRIN, Nancy, France.
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14
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Iyngkaran P, Toukhsati SR, Thomas MC, Jelinek MV, Hare DL, Horowitz JD. A Review of the External Validity of Clinical Trials with Beta-Blockers in Heart Failure. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:163-171. [PMID: 27773994 PMCID: PMC5063839 DOI: 10.4137/cmc.s38444] [Citation(s) in RCA: 2] [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] [Received: 03/16/2016] [Revised: 07/03/2016] [Accepted: 07/16/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Beta-blockers (BBs) are the mainstay prognostic medication for all stages of chronic heart failure (CHF). There are many classes of BBs, each of which has varying levels of evidence to support its efficacy in CHF. However, most CHF patients have one or more comorbid conditions such as diabetes, renal impairment, and/or atrial fibrillation. Patient enrollment to randomized controlled trials (RCTs) often excludes those with certain comorbidities, particularly if the symptoms are severe. Consequently, the extent to which evidence drawn from RCTs is generalizable to CHF patients has not been well described. Clinical guidelines also underrepresent this point by providing generic advice for all patients. The aim of this review is to examine the evidence to support the use of BBs in CHF patients with common comorbid conditions. METHODS We searched MEDLINE, PubMed, and the reference lists of reviews for RCTs, post hoc analyses, systematic reviews, and meta-analyses that report on use of BBs in CHF along with patient demographics and comorbidities. RESULTS In total, 38 studies from 28 RCTs were identified, which provided data on six BBs against placebo or head to head with another BB agent in ischemic and nonischemic cardiomyopathies. Several studies explored BBs in older patients. Female patients and non-Caucasian race were underrepresented in trials. End points were cardiovascular hospitalization and mortality. Comorbid diabetes, renal impairment, or atrial fibrillation was detailed; however, no reference to disease spectrum or management goals as a focus could be seen in any of the studies. In this sense, enrollment may have limited more severe grades of these comorbidities. CONCLUSIONS RCTs provide authoritative information for a spectrum of CHF presentations that support guidelines. RCTs may provide inadequate information for more heterogeneous CHF patient cohorts. Greater Phase IV research may be needed to fill this gap and inform guidelines for a more global patient population.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist and Senior Lecturer, Northern Territory School of Medicine, Flinders University, Bedford Park, South Australia
| | - Samia R Toukhsati
- Department of Cardiology, Austin Health, Heidelberg, Victoria, Australia
| | - Merlin C Thomas
- Professor, NHMRC Senior Research Fellow, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Michael V Jelinek
- Professor, Department of Cardiology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - David L Hare
- Professor, Coordinator, Cardiovascular Research, University of Melbourne; Director of Heart Failure Services, Austin Health, Melbourne, Victoria, Australia
| | - John D Horowitz
- Professor of Cardiology, Director, Cardiology Unit, Discipline of Medicine, Cardiology Research Laboratory, The Basil Hetzel Institute, Woodville South, South Australia, Australia
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15
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Goldberger JJ, Bonow RO, Cuffe M, Liu L, Rosenberg Y, Shah PK, Smith SC, Subačius H. Effect of Beta-Blocker Dose on Survival After Acute Myocardial Infarction. J Am Coll Cardiol 2015; 66:1431-41. [PMID: 26403339 DOI: 10.1016/j.jacc.2015.07.047] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 07/20/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Beta-blocker therapy after acute myocardial infarction (MI) improves survival. Beta-blocker doses used in clinical practice are often substantially lower than those used in the randomized trials establishing their efficacy. OBJECTIVES This study evaluated the association of beta-blocker dose with survival after acute MI, hypothesizing that higher dose beta-blocker therapy will be associated with increased survival. METHODS A multicenter registry enrolled 7,057 consecutive patients with acute MI. Discharge beta-blocker dose was indexed to the target beta-blocker doses used in randomized clinical trials, grouped as >0% to 12.5%, >12.5% to 25%, >25% to 50%, and >50% of target dose. Follow-up vital status was assessed, with the primary endpoint of time-to-death right-censored at 2 years. Multivariable and propensity score analyses were used to account for group differences. RESULTS Of 6,682 patients with follow-up (median 2.1 years), 91.5% were discharged on a beta-blocker (mean dose 38.1% of the target dose). Lower mortality was observed with all beta-blocker doses (p < 0.0002) versus no beta-blocker therapy. After multivariable adjustment, hazard ratios for 2-year mortality compared with the >50% dose were 0.862 (95% confidence interval [CI]: 0.677 to 1.098), 0.799 (95% CI: 0.635 to 1.005), and 0.963 (95% CI: 0.765 to 1.213) for the >0% to 12.5%, >12.5% to 25%, and >25% to 50% of target dose groups, respectively. Multivariable analysis with an extended set of covariates and propensity score analysis also demonstrated that higher doses were not associated with better outcome. CONCLUSIONS These data do not demonstrate increased survival in patients treated with beta-blocker doses approximating those used in previous randomized clinical trials compared with lower doses. These findings provide the rationale to re-engage in research to establish appropriate beta-blocker dosing after MI to derive optimal benefit from this therapy. (The PACE-MI Registry Study-Outcomes of Beta-blocker Therapy After Myocardial Infarction [OBTAIN]: NCT00430612).
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Affiliation(s)
- Jeffrey J Goldberger
- Center for Cardiovascular Innovation and the Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Robert O Bonow
- Center for Cardiovascular Innovation and the Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael Cuffe
- Hospital Corporation of America, Brentwood, Tennessee
| | - Lei Liu
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Yves Rosenberg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Prediman K Shah
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sidney C Smith
- Heart and Vascular Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Haris Subačius
- Center for Cardiovascular Innovation and the Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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16
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Edelmann F, Musial-Bright L, Gelbrich G, Trippel T, Radenovic S, Wachter R, Inkrot S, Loncar G, Tahirovic E, Celic V, Veskovic J, Zdravkovic M, Lainscak M, Apostolović S, Neskovic AN, Pieske B, Düngen HD. Tolerability and Feasibility of Beta-Blocker Titration in HFpEF Versus HFrEF: Insights From the CIBIS-ELD Trial. JACC-HEART FAILURE 2015; 4:140-149. [PMID: 26682793 DOI: 10.1016/j.jchf.2015.10.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/09/2015] [Accepted: 10/15/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study evaluated the tolerability and feasibility of titration of 2 distinctly acting beta-blockers (BB) in elderly heart failure patients with preserved (HFpEF) and reduced (HFrEF) left ventricular ejection fraction. BACKGROUND Broad evidence supports the use of BB in HFrEF, whereas the evidence for beta blockade in HFpEF is uncertain. METHODS In the CIBIS-ELD (Cardiac Insufficiency Bisoprolol Study in Elderly) trial, patients >65 years of age with HFrEF (n = 626) or HFpEF (n = 250) were randomized to bisoprolol or carvedilol. Both BB were up-titrated to the target or maximum tolerated dose. Follow-up was performed after 12 weeks. HFrEF and HFpEF patients were compared regarding tolerability and clinical effects (heart rate, blood pressure, systolic and diastolic functions, New York Heart Association functional class, 6-minute-walk distance, quality of life, and N-terminal pro-B-type natriuretic peptide). RESULTS For both of the BBs, tolerability and daily dose at 12 weeks were similar. HFpEF patients demonstrated higher rates of dose escalation delays and treatment-related side effects. Similar HR reductions were observed in both groups (HFpEF: 6.6 beats/min; HFrEF: 6.9 beats/min, p = NS), whereas greater improvement in NYHA functional class was observed in HFrEF (HFpEF: 23% vs. HFrEF: 34%, p < 0.001). Mean E/e' and left atrial volume index did not change in either group, although E/A increased in HFpEF. CONCLUSIONS BB tolerability was comparable between HFrEF and HFpEF. Relevant reductions of HR and blood pressure occurred in both groups. However, only HFrEF patients experienced considerable improvements in clinical parameters and left ventricular function. Interestingly, beta-blockade had no effect on established and prognostic markers of diastolic function in either group. Long-term studies using modern diagnostic criteria for HFpEF are urgently needed to establish whether BB therapy exerts significant clinical benefit in HFpEF. (Comparison of Bisoprolol and Carvedilol in Elderly Heart Failure [HF] PATIENTS A Randomised, Double-Blind Multicentre Study [CIBIS-ELD]; ISRCTN34827306).
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Affiliation(s)
- Frank Edelmann
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany; Department of Cardiology and Pneumology, Göttingen University Medical Center, Göttingen, Germany; DZHK Partner Site Berlin, Berlin, Germany; DZHK Partner Site Göttingen, Göttingen, Germany
| | - Lindy Musial-Bright
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany
| | - Goetz Gelbrich
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany; Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Tobias Trippel
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany; DZHK Partner Site Berlin, Berlin, Germany
| | - Sara Radenovic
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany; DZHK Partner Site Berlin, Berlin, Germany
| | - Rolf Wachter
- Department of Cardiology and Pneumology, Göttingen University Medical Center, Göttingen, Germany; DZHK Partner Site Göttingen, Göttingen, Germany
| | - Simone Inkrot
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany
| | - Goran Loncar
- Department of Cardiology, Clinical Hospital Zvezdara, Belgrade, Serbia
| | - Elvis Tahirovic
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany; DZHK Partner Site Berlin, Berlin, Germany
| | - Vera Celic
- Cardiology Department, University Clinical Hospital Center Dr. Dragisa Misovic, Belgrade, Serbia and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jovan Veskovic
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany
| | - Marija Zdravkovic
- Department of Cardiology, Faculty of Medicine, University Hospital Medical Center Bezanijska kosa, University of Belgrade, Belgrade, Serbia
| | - Mitja Lainscak
- Department of Cardiology and Department of Research and Education, General Hospital Celje, Celje, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Aleksandar N Neskovic
- Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Burkert Pieske
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany; DZHK Partner Site Berlin, Berlin, Germany
| | - Hans-Dirk Düngen
- Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinkum, Berlin, Germany; DZHK Partner Site Berlin, Berlin, Germany.
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Abstract
Nebivolol is a highly selective β1-adrenergic receptor antagonist with a pharmacologic profile that differs from those of other drugs in its class. In addition to cardioselectivity mediated via β1 receptor blockade, nebivolol induces nitric oxide-mediated vasodilation by stimulating endothelial nitric oxide synthase via β3 agonism. This vasodilatory mechanism is distinct from those of other vasodilatory β-blockers (carvedilol, labetalol), which are mediated via α-adrenergic receptor blockade. Nebivolol is approved for the treatment of hypertension in the US, and for hypertension and heart failure in Europe. While β-blockers are not recommended within the current US guidelines as first-line therapy for treatment of essential hypertension, nebivolol has shown comparable efficacy to currently recommended therapies in lowering peripheral blood pressure in adults with hypertension with a very low rate of side effects. Nebivolol also has beneficial effects on central blood pressure compared with other β-blockers. Clinical data also suggest that nebivolol may be useful in patients who have experienced erectile dysfunction while on other β-blockers. Here we review the pharmacological profile of nebivolol, the clinical evidence supporting its use in hypertension as monotherapy, add-on, and combination therapy, and the data demonstrating its positive effects on heart failure and endothelial dysfunction.
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Affiliation(s)
- Justin Fongemie
- />Tufts Medical Center, 800 Washington St., Boston, MA 02111 USA
| | - Erika Felix-Getzik
- />MCPHS University, School of Pharmacy-Boston, 179 Longwood Ave, Boston, MA 02115 USA
- />Newton-Wellesley Hospital, 2014 Washington St, Newton, MA 02462 USA
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18
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Krum H, van Veldhuisen DJ, Funck-Brentano C, Vanoli E, Silke B, Erdmann E, Follath F, Ponikowski P, Goulder M, Meyer W, Lechat P, Willenheimer R. Effect on mode of death of heart failure treatment started with bisoprolol followed by Enalapril, compared to the opposite order: results of the randomized CIBIS III trial. Cardiovasc Ther 2015; 29:89-98. [PMID: 20528880 DOI: 10.1111/j.1755-5922.2010.00185.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Mode of death in chronic heart failure (CHF) may be of relevance to choice of therapy for this condition. Sudden death is particularly common in patients with early and/or mild/moderate CHF. β-Blockade may provide better protection against sudden death than ACE inhibition (ACEI) in this setting. METHODS We randomized 1010 patients with mild or moderate, stable CHF and left ventricular ejection fraction ≤35%, without ACEI, β-blocker or angiotensin-receptor-blocker therapy, to either bisoprolol (n = 505) or enalapril (n = 505) for 6 months, followed by their combination for 6-24 months. The two strategies were blindly compared regarding adjudicated mode of death, including sudden death and progressive pump failure death. RESULTS During the monotherapy phase, 8 of 23 deaths in the bisoprolol-first group were sudden, compared to 16 of 32 in the enalapril-first group: hazard ratio (HR) for sudden death 0.50; 95% confidence interval (CI) 0.21-1.16; P= 0.107. At 1 year, 16 of 42 versus 29 of 60 deaths were sudden: HR 0.54; 95% CI 0.29-1.00; P= 0.049. At study end, 29 of 65 versus 34 of 73 deaths were sudden: HR 0.84; 95% CI 0.51-1.38; P= 0.487. Comparable figures for pump failure death were: monotherapy, 7 of 23 deaths versus 2 of 32: HR 3.43; 95% CI 0.71-16.53; P= 0.124, at 1 year, 13 of 42 versus 5 of 60: HR 2.57; 95% CI 0.92-7.20; P= 0.073, at study end, 17 of 65 versus 7 of 73: HR 2.39; 95% CI 0.99-5.75; P= 0.053. There were no significant between-group differences in any other fatal events. CONCLUSION Initiating therapy with bisoprolol compared to enalapril decreased the risk of sudden death during the first year in this mild systolic CHF cohort. This was somewhat offset by an increase in pump failure deaths in the bisoprolol-first cohort.
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Affiliation(s)
- Henry Krum
- Departments of Epidemiology and Preventive Medicine and Medicine, Monash University, Alfred Hospital, Melbourne, Australia Thoraxcenter, Department of Cardiology, University Hospital Groningen, The Netherlands UPMC - AP-HP - INSERM CIC9304, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France Department of Cardiology, University of Pavia and Policlinico di Monza, Italy Department of Pharmacology & Therapeutics, Trinity Centre, St James' Hospital, Dublin, Ireland Medizinische Klinik III, University of Cologne, Germany Medicine A, University Hospital Zürich, Switzerland Department of Heart Diseases, Medical University, Wroclaw, Poland Worldwide Clinical Trials, Nottingham, UK Merck KGaA, Darmstadt, Germany Service de Pharmacologie, Hopital Pitié-Salpetriere, Paris, France Lund University and Heart Health Group, Malmö, Sweden
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Kaldara E, Sanoudou D, Adamopoulos S, Nanas JN. Outpatient management of chronic heart failure. Expert Opin Pharmacother 2014; 16:17-41. [PMID: 25480690 DOI: 10.1517/14656566.2015.978286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Heart failure (HF) treatment attracts a share of intensive research because of its poor HF prognosis. In the past decades, the prognosis of HF has improved considerably, mainly as a consequence of the progress that has been made in the pharmacological management of HF. AREAS COVERED This article reviews the outpatient pharmacological management of chronic HF due to left ventricular systolic dysfunction and offers recommendations on the use of various drugs. In addition, the present article attempts to provide practical therapeutic algorithms based on current clinical strategies. EXPERT OPINION Continued research directed toward identifying factors associated with high pharmacotherapy guideline adherence and understanding of variants that influence response to drugs will hopefully halt or reverse the major pathophysiological mechanisms involved in this syndrome.
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Affiliation(s)
- Elisabeth Kaldara
- University of Athens, Medical School, 3rd Cardiology Department , Mikras Asias 67, 11527 Attiki, Athens , Greece +30 2108236877 ; +30 2107789901 ;
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Zhang Z, Ding L, Jin Z, Gao G, Li H, Zhang L, Zhang L, Lu X, Hu L, Lu B, Yu X, Hu T. Nebivolol protects against myocardial infarction injury via stimulation of beta 3-adrenergic receptors and nitric oxide signaling. PLoS One 2014; 9:e98179. [PMID: 24849208 PMCID: PMC4029889 DOI: 10.1371/journal.pone.0098179] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/29/2014] [Indexed: 11/26/2022] Open
Abstract
Nebivolol, third-generation β-blocker, may activate β3-adrenergic receptor (AR), which has been emerged as a novel and potential therapeutic targets for cardiovascular diseases. However, it is not known whether nebivolol administration plays a cardioprotective effect against myocardial infarction (MI) injury. Therefore, the present study was designed to clarify the effects of nebivolol on MI injury and to elucidate the underlying mechanism. MI model was constructed by left anterior descending (LAD) artery ligation. Nebivolol, β3-AR antagonist (SR59230A), Nitro-L-arginine methylester (L-NAME) or vehicle was administered for 4 weeks after MI operation. Cardiac function was monitored by echocardiography. Moreover, the fibrosis and the apoptosis of myocardium were assessed by Masson's trichrome stain and TUNEL assay respectively 4 weeks after MI. Nebivolol administration reduced scar area by 68% compared with MI group (p<0.05). Meanwhile, nebivolol also decreased the myocardial apoptosis and improved the heart function after MI (p<0.05 vs. MI). These effects were associated with increased β3-AR expression. Moreover, nebivolol treatment significantly increased the phosphorylation of endothelial NOS (eNOS) and the expression of neuronal NOS (nNOS). Conversely, the cardiac protective effects of nebivolol were abolished by SR and L-NAME. These results indicate that nebivolol protects against MI injury. Furthermore, the cardioprotective effects of nebivolol may be mediated by β3-AR-eNOS/nNOS pathway.
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Affiliation(s)
- Zheng Zhang
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Liping Ding
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Zhitao Jin
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Guojie Gao
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Huijun Li
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Lijuan Zhang
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Lina Zhang
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Xin Lu
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Lihua Hu
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Bingwei Lu
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Xiongjun Yu
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Taohong Hu
- Department of Cardiology, The Second Artillery General Hospital of Chinese People's Liberation Army, Beijing, China
- * E-mail:
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Málek F. Reaching betablockers target dose in elderly patients with chronic heart failure. COR ET VASA 2014. [DOI: 10.1016/j.crvasa.2014.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Dobre D, Borer JS, Fox K, Swedberg K, Adams KF, Cleland JGF, Cohen-Solal A, Gheorghiade M, Gueyffier F, O'Connor CM, Fiuzat M, Patak A, Piña IL, Rosano G, Sabbah HN, Tavazzi L, Zannad F. Heart rate: a prognostic factor and therapeutic target in chronic heart failure. The distinct roles of drugs with heart rate-lowering properties. Eur J Heart Fail 2013; 16:76-85. [PMID: 23928650 DOI: 10.1093/eurjhf/hft129] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 04/16/2013] [Accepted: 05/31/2013] [Indexed: 01/09/2023] Open
Abstract
Heart rate not only predicts outcome but may also be a therapeutic target in patients with chronic heart failure. Several classes of pharmacological agents can be used to modulate heart rate, including beta-blockers, ivabradine, digoxin, amiodarone, and verapamil. Choice of agent will depend on heart rhythm, co-morbidities, and disease phenotype. Beneficial and harmful interactions may also exist. The aim of this paper is to summarize the current body of knowledge regarding the relevance of heart rate as a prognostic factor (risk marker) and particularly as a therapeutic target (risk factor) in patients with chronic heart failure, with a special focus on ivabradine, a novel agent that is currently the only available purely bradycardic agent.
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Affiliation(s)
- Daniela Dobre
- INSERM, Center of Clinical Investigation 9501, Institut Lorrain du Coeur et des Vaisseaux, CHU Nancy, Université de Lorraine, Nancy, France
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Kotecha D, Manzano L, Altman DG, Krum H, Erdem G, Williams N, Flather MD. Individual patient data meta-analysis of beta-blockers in heart failure: rationale and design. Syst Rev 2013; 2:7. [PMID: 23327629 PMCID: PMC3564787 DOI: 10.1186/2046-4053-2-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 12/03/2012] [Indexed: 12/16/2022] Open
Abstract
UNLABELLED The Beta-Blockers in Heart Failure Collaborative Group (BB-HF) was formed to obtain and analyze individual patient data from the major randomized controlled trials of beta-blockers in heart failure. Even though beta-blockers are an established treatment for heart failure, uptake is still sub-optimal. Further, the balance of efficacy and safety remains uncertain for common groups including older persons, women, those with impaired renal function and diabetes. Our aim is to provide clinicians with a thorough and definitive evidence-based assessment of these agents. We have identified 11 large randomized trials of beta-blockers versus placebo in heart failure and plan to meta-analyze the data on an individual patient level. In total, these trials have enrolled 18,630 patients. Uniquely, the BB-HF group has secured access to the individual data for all of these trials, with the participation of key investigators and pharmaceutical companies.Our principal objectives include deriving an overall estimate of efficacy for all-cause mortality and cardiovascular hospitalization. Importantly, we propose a statistically-robust sub-group assessment according to age, gender, diabetes and other key factors; analyses which are only achievable using an individual patient data meta-analysis. Further, we aim to provide an assessment of economic benefit and develop a risk model for the prognosis of patients with chronic heart failure.This paper outlines inclusion criteria, search strategies, outcome measures and planned statistical analyses. CLINICAL TRIAL REGISTRATION INFORMATION http://clinicaltrials.gov/ct2/show/NCT00832442.
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Affiliation(s)
- Dipak Kotecha
- Clinical Trials and Evaluation Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
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Effect of Fixed-Dose Combined Isosorbide Dinitrate/Hydralazine in Elderly Patients in the African-American Heart Failure Trial. J Card Fail 2012; 18:600-6. [DOI: 10.1016/j.cardfail.2012.06.526] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 06/08/2012] [Accepted: 06/15/2012] [Indexed: 11/23/2022]
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Kitakaze M, Sarai N, Ando H, Sakamoto T, Nakajima H. Safety and tolerability of once-daily controlled-release carvedilol 10-80 mg in Japanese patients with chronic heart failure. Circ J 2012; 76:668-74. [PMID: 22240593 DOI: 10.1253/circj.cj-11-0210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of the present study was to assess the safety and tolerability of the controlled-release (CR) formulation of the β-blocker carvedilol in Japanese patients with chronic heart failure (HF). METHODS AND RESULTS In this multicenter, randomized, open-label, phase I/II dose-escalation study, 41 patients receiving standard therapy for chronic HF were randomized in a ratio of 1:1 to carvedilol CR or immediate-release (IR) carvedilol. The primary objective was to evaluate the tolerability and safety of escalating doses of carvedilol CR (10-40 mg/day), with a reference arm of 5-20 mg/day of carvedilol IR. In addition, the tolerability and safety of titration to a carvedilol CR dose up to 80 mg/day were examined, as were plasma concentrations of carvedilol and changes in vital signs. The proportions of patients who completed 40-mg/day carvedilol CR and 20-mg/day carvedilol IR were 42% (8/19) and 50% (11/22), respectively. In the CR group, 7/19 (37%) attained a dose of 80 mg. During the primary evaluation period, 7/19 (37%) and 4/22 (18%) patients experienced drug-related adverse events in the CR and IR groups, respectively, the characteristics of which were similar between groups. CONCLUSIONS No new safety issues emerged in Japanese chronic HF patients treated with carvedilol CR in contrast to those known in carvedilol IR.
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Affiliation(s)
- Masafumi Kitakaze
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Suita, Japan
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Affiliation(s)
- Nicoletta Riva
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
| | - Gregory YH Lip
- University of Birmingham, City Hospital, Centre for Cardiovascular Sciences, Birmingham B18 7QH, UK ;
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Dery AS, Hamilton LA, Starr JA. Nebivolol for the treatment of heart failure. Am J Health Syst Pharm 2011; 68:879-86. [PMID: 21546638 DOI: 10.2146/ajhp100309] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE. The pharmacology, pharmacokinetics, efficacy, safety, and place in therapy of nebivolol are reviewed. SUMMARY. Nebivolol, a third-generation, highly β(1)-specific β-blocker, is labeled for the treatment of hypertension in the United States. In addition to its β-blocking effects, nebivolol has been shown to increase endothelin-dependent nitric oxide, giving it a unique peripheral vasodilatory action. Nebivolol is extensively metabolized by cytochrome P-450 isoenzyme 2D6. In patients with heart failure, certain β-blockers antagonize excessive adrenergic stimulation and can slow the progression of the disease. Clinical trials have compared nebivolol at target dosages of 5 and 10 mg once daily with placebo and, in small trials, with carvedilol in the treatment of adults with chronic heart failure. Nebivolol appears to have beneficial effects in patients with heart failure, including improvements in left ventricular ejection fraction, left ventricular volumes, and exercise capacity. In addition, the Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with Heart Failure showed a reduction in morbidity and mortality after treatment with nebivolol when compared with placebo, though this effect appeared to be less than that of other β-blockers currently recommended for the treatment of heart failure. Nebivolol was well tolerated in all clinical trials, with the most frequently reported adverse events including bradycardia, hypotension, and dizziness. To date, no large clinical trials have compared nebivolol with currently recommended β-blockers in patients with heart failure. CONCLUSION. Nebivolol has beneficial effects in heart failure but cannot be considered equivalent to other currently accepted therapies.
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Funck-Brentano C, van Veldhuisen DJ, van de Ven LLM, Follath F, Goulder M, Willenheimer R. Influence of order and type of drug (bisoprolol vs. enalapril) on outcome and adverse events in patients with chronic heart failure: a post hoc analysis of the CIBIS-III trial. Eur J Heart Fail 2011; 13:765-72. [PMID: 21551161 DOI: 10.1093/eurjhf/hfr051] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Angiotensin-converting enzyme inhibitors (ACE-Is) and beta-blockers are associated with improved outcome in patients with chronic heart failure (CHF). In this post hoc analysis of the CIBIS III trial, we examined the influence of the order of drug administration on clinical events and achieved dose. We also assessed the relations between dose levels and baseline variables or adverse events. METHODS AND RESULTS In the CIBIS III trial, 1010 patients (mean age: 72.4 years; mean ejection fraction: 28.8%; male: 68.2%) with stable CHF were randomized to up-titration of monotherapy with either bisoprolol (target dose 10 mg o.d.) or enalapril (target dose 10 mg b.i.d.) for 6 months, followed by their combination for 6-24 months. Endpoints were mortality or all-cause hospitalization, mortality alone and mortality or cardiovascular hospitalization. The study drug (ACE-I or beta-blocker) was last prescribed at ≥50% of target dose to significantly more patients for the first initiated drug in both treatment groups (both P< 0.001). Sixty per cent of endpoints were reached during the monotherapy phase and randomized treatment during monotherapy was not a predictor of the three assessed outcomes. Monotherapy phase was the strongest independent predictor of outcome (P< 0.0001 for all endpoints). Older age, NYHA class III, impaired renal function, lower body weight and blood pressure at baseline, and hypotension, bradycardia and heart failure during treatment were associated with the inability to reach high dose of both study drugs. CONCLUSION The order of drug administration plays an important role in whether CHF patients reach target doses of bisoprolol and enalapril. For both study drugs, the dose level reached was associated with baseline characteristics and adverse events. In CHF patients not treated with an ACE-I or a beta-blocker, the duration of monotherapy with either type of drug should be shorter than 6 months.
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Düngen HD, Apostolovic S, Inkrot S, Tahirovic E, Töpper A, Mehrhof F, Prettin C, Putnikovic B, Neskovic AN, Krotin M, Sakac D, Lainscak M, Edelmann F, Wachter R, Rau T, Eschenhagen T, Doehner W, Anker SD, Waagstein F, Herrmann-Lingen C, Gelbrich G, Dietz R. Titration to target dose of bisoprolol vs. carvedilol in elderly patients with heart failure: the CIBIS-ELD trial. Eur J Heart Fail 2011; 13:670-80. [PMID: 21429992 PMCID: PMC3101867 DOI: 10.1093/eurjhf/hfr020] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aims Various beta-blockers with distinct pharmacological profiles are approved in heart failure, yet they remain underused and underdosed. Although potentially of major public health importance, whether one agent is superior in terms of tolerability and optimal dosing has not been investigated. The aim of this study was therefore to compare the tolerability and clinical effects of two proven beta-blockers in elderly patients with heart failure. Methods and results We performed a double-blind superiority trial of bisoprolol vs. carvedilol in 883 elderly heart failure patients with reduced or preserved left ventricular ejection fraction in 41 European centres. The primary endpoint was tolerability, defined as reaching and maintaining guideline-recommended target doses after 12 weeks treatment. Adverse events and clinical parameters of patient status were secondary endpoints. None of the beta-blockers was superior with regards to tolerability: 24% [95% confidence interval (CI) 20–28] of patients in the bisoprolol arm and 25% (95% CI 21–29) of patients in the carvedilol arm achieved the primary endpoint (P= 0.64). The use of bisoprolol resulted in greater reduction of heart rate (adjusted mean difference 2.1 b.p.m., 95% CI 0.5–3.6, P= 0.008) and more, dose-limiting, bradycardic adverse events (16 vs. 11%; P= 0.02). The use of carvedilol led to a reduction of forced expiratory volume (adjusted mean difference 50 mL, 95% CI 4–95, P= 0.03) and more, non-dose-limiting, pulmonary adverse events (10 vs. 4%; P < 0.001). Conclusion Overall tolerability to target doses was comparable. The pattern of intolerance, however, was different: bradycardia occurred more often in the bisoprolol group, whereas pulmonary adverse events occurred more often in the carvedilol group. This study is registered with controlled-trials.com, number ISRCTN34827306.
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Affiliation(s)
- Hans-Dirk Düngen
- Department of Internal Medicine-Cardiology, Charité-Universitätsmedizin, Competence Network Heart Failure, Campus Virchow-Klinkum, Berlin, Germany.
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Abstract
Beta blockers have been used in the treatment of cardiovascular conditions for decades. Despite a long history and status as a guideline-recommended treatment option for hypertension, recent meta-analyses have brought into question whether β blockers are still an appropriate therapy given outcomes data from other antihypertensive drug classes. However, β blockers are a heterogenous class of agents with diverse pharmacologic and physiologic properties. Much of the unfavorable data revealed in the recent meta-analyses were gleaned from studies involving nonvasodilating, traditional β blockers, such as atenolol. However, findings with traditional β blockers may not be extrapolated to other members of the class, particularly those agents with vasodilatory activity. Vasodilatory β blockers (i.e., carvedilol and nebivolol) reduce blood pressure in large part through reducing systemic vascular resistance rather than by decreasing cardiac output, as is observed with traditional β blockers. Vasodilating ability may also ameliorate some of the concerns associated with traditional β blockade, such as the adverse effects on metabolic and lipid parameters, including an increased risk for new-onset diabetes. Furthermore, vasodilating ability is physiologically relevant and important in treating a condition with common co-morbidities involving metabolic and lipid abnormalities such as hypertension. In patients with hypertension and diabetes or coronary artery disease, vasodilating β blockers provide effective blood pressure control with neutral or beneficial effects on important parameters for the co-morbid disease. In conclusion, it is time for a reexamination of the clinical evidence for the use of β blockers in hypertension, recognizing that there are patients for whom β blockers, particularly those with vasodilatory actions, are an appropriate treatment option.
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Del Sindaco D, Tinti MD, Monzo L, Pulignano G. Clinical and economic aspects of the use of nebivolol in the treatment of elderly patients with heart failure. Clin Interv Aging 2010; 5:381-93. [PMID: 21152240 PMCID: PMC2998246 DOI: 10.2147/cia.s4482] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Heart failure is a common and disabling condition with morbidity and mortality that increase dramatically with advancing age. Large observational studies, retrospective subgroup analyses and meta-analyses of clinical trials in systolic heart failure, and recently published randomized studies have provided data supporting the use of beta-blockers as a baseline therapy in heart failure in the elderly. Despite the available evidence about beta-blockers, this therapy is still less frequently used in elderly compared to younger patients. Nebivolol is a third-generation cardioselective beta-blocker with L-arginine/nitric oxide-induced vasodilatory properties, approved in Europe and several other countries for the treatment of essential hypertension, and in Europe for the treatment of stable, mild, or moderate chronic heart failure, in addition to standard therapies in elderly patients aged 70 years old or older. The effects of nebivolol on left ventricular function in elderly patients with chronic heart failure (ENECA) and the study of effects of nebivolol intervention on outcomes and rehospitalization in seniors with heart failure (SENIORS) have been specifically aimed to assess the efficacy of beta-blockade in elderly heart failure patients. The results of these two trials demonstrate that nebivolol is well tolerated and effective in reducing mortality and morbidity in older patients, and that the beneficial clinical effect is present also in patients with mildly reduced ejection fraction. Moreover, nebivolol appears to be significantly cost-effective when prescribed in these patients. However, further targeted studies are needed to better define the efficacy as well as safety profile in frail and older patients with comorbid diseases.
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Affiliation(s)
- Donatella Del Sindaco
- Heart Failure Unit, Division of Cardiology, INRCA Institute of Care and Research for Elderly, Rome, Italy.
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Arif SA, Mergenhagen KA, Del Carpio ROD, Ho C. Treatment of systolic heart failure in the elderly: an evidence-based review. Ann Pharmacother 2010; 44:1604-14. [PMID: 20841514 DOI: 10.1345/aph.1p128] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review relevant literature supporting the use of β-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), diuretics, digoxin, aldosterone antagonists, and vasodilators in the management of heart failure in an elderly patient population aged ≥65 years. DATA SOURCES PubMed, EMBASE, and MEDLINE searches (January 1960-April 2010) were utilized to identify primary literature using the key terms heart failure, treatment, and elderly. Additionally, reference citations from publications identified were utilized, as well as the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult. STUDY SELECTION AND DATA EXTRACTION Primary and tertiary literature, including subgroup analyses, published in English and relating to the use of pharmacotherapy in the treatment of systolic heart failure in the elderly was reviewed. DATA SYNTHESIS The aging of the US population is creating a higher prevalence of systolic heart failure in the elderly. Most clinical trials have established the mortality and morbidity benefit of pharmacotherapy in heart failure in nonelderly patients; however, the current ACC/AHA guidelines do not clearly delineate this benefit in persons ≥65 years of age. CONCLUSIONS Clinical trial data, based on limited numbers of individuals aged ≥65 years, suggest that use of β-blockers, ACE inhibitors, ARBs, aldosterone antagonists, and vasodilators (hydralazine/nitrates) have similar mortality benefit to that observed in younger patients. As supported in the ACC/AHA guidelines, these agents should be prescribed with clinical judgment to all elderly patients, with close monitoring for adverse events. Future clinical trials with greater inclusion of patients ≥65 years will help to elucidate the magnitude of benefits of optimal pharmacotherapy on mortality and morbidity rates in this population.
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Goldberger JJ, Bonow RO, Cuffe M, Dyer A, Rosenberg Y, O'Rourke R, Shah PK, Smith SC. beta-Blocker use following myocardial infarction: low prevalence of evidence-based dosing. Am Heart J 2010; 160:435-442.e1. [PMID: 20826250 DOI: 10.1016/j.ahj.2010.06.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 06/15/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Quality improvement programs have shown increased use of beta-blockers post-myocardial infarction (MI), but there are no data on whether appropriate doses are administered. METHODS In a prospective registry that enrolled consecutive patients with MI, we evaluated beta-blocker dosing at discharge after MI and 3 weeks later and assessed clinical predictors for treatment with very low doses. We studied 1,971 patients (70.8% male) with a mean age of 63.9 +/- 13.7 years, of whom 48.2% had an ST-elevation MI. RESULTS beta-Blocker utilization rates following MI were 93.2% at discharge: 20.1% received <25% of target dose, 36.5% received 25% of target dose, 26.4% received 26% to 50% of target dose, and 17.0% received >50% of target dose. Between discharge and 3 weeks, 76.4% had no change in beta-blocker dose, with 11.9% and 11.6% having their dose reduced and increased, respectively. Absence of hypertension, acute percutaneous coronary intervention, older age, and no angiotensin-converting enzyme inhibitor therapy were consistent predictors of treatment with very low beta-blocker doses. CONCLUSIONS Underdosing of beta-blockers is highly prevalent among patients post-MI. This represents an important opportunity in quality improvement for the care of patients who have suffered an MI.
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de Boer RA, Doehner W, van der Horst ICC, Anker SD, Babalis D, Roughton M, Coats AJ, Flather MD, van Veldhuisen DJ. Influence of diabetes mellitus and hyperglycemia on prognosis in patients > or =70 years old with heart failure and effects of nebivolol (data from the Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with heart failure [SENIORS]). Am J Cardiol 2010; 106:78-86.e1. [PMID: 20609652 DOI: 10.1016/j.amjcard.2010.02.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 02/07/2010] [Accepted: 02/07/2010] [Indexed: 11/17/2022]
Abstract
The beneficial effects of beta blockers in younger patients with heart failure (HF) due to systolic dysfunction are well established. However, data from patients > or =70 years old with diabetes mellitus and HF are lacking. The Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with heart failure [SENIORS] tested the efficacy of the vasodilator beta blocker nebivolol in patients > or =70 years old with HF and impaired or preserved left ventricular ejection fraction. In the present analysis, we evaluated the association between diabetes mellitus and baseline glucose levels on the primary outcome (all-cause mortality and cardiovascular hospitalization) and secondary end points, including all-cause mortality, cardiovascular hospitalizations, and cardiovascular mortality. Of 2,128 patients, 555 (26.1%) had diabetes mellitus. Of the 555 patients with diabetes mellitus, 223 (40.2%) experienced the primary end point compared to 484 (30.8%) of the 1,573 nondiabetic patients (p <0.001). For the nondiabetic patients, the rate of the primary outcome for placebo compared to nebivolol was 33.7% for the placebo group and 27.8% for the nebivolol group (hazard ratio 0.78, 95% confidence interval 0.65 to 0.93; p = 0.006). In the diabetic subset, the rate was 40.3% for the placebo group and 40.1% for the nebivolol group (hazard ratio 1.04, 95% confidence interval 0.80 to 1.35, p = 0.773). The subgroup interaction p value was 0.073. The baseline glucose levels in the nondiabetic patients did not significantly affect the outcomes. The effect of diabetes mellitus on outcome was independent of the left ventricular ejection fraction and was most pronounced in those with HF due to a nonischemic etiology. In conclusion, in patients > or =70 years old with HF, diabetes mellitus was associated with a worse prognosis. Nebivolol was less effective in the patients with diabetes and HF than in those with HF but without diabetes who were > or =70 years old.
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Affiliation(s)
- Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands.
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Lipsic E, van Veldhuisen DJ. Nebivolol in chronic heart failure: current evidence and future perspectives. Expert Opin Pharmacother 2010; 11:983-92. [PMID: 20307222 DOI: 10.1517/14656561003694650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Chronic activation of the sympathetic nervous system leads to deterioration of cardiovascular function in heart failure patients. In systolic heart failure, beta-blockers were proven to be effective in decreasing the number of deaths and improving morbidity. However, beta-blockers are a heterogeneous drug group, consisting of agents with different selectivity for adrenergic receptors and/or additional effects in heart or peripheral circulation. AREAS COVERED IN THE REVIEW We describe the role of the sympathetic nervous system, beta-blockers and specifically nebivolol in chronic heart failure. WHAT THE READER WILL GAIN Nebivolol is a third-generation beta-blocker, with high beta(1)/beta(2) selectivity. Moreover, it has important vasodilating properties, by stimulating the production of nitric oxide. Smaller studies have already shown beneficial effects of nebivolol treatment on surrogate end points in heart failure patients. The recently published SENIORS (Phase III) study in an elderly heart failure population demonstrated a decreased number of clinical events in patients treated with nebivolol. Importantly, this effect was observed in patients with both impaired and preserved left ventricular systolic function. TAKE HOME MESSAGE Specific beta-blockers may have distinct effects in various subgroups of heart failure patients. So far, nebivolol is the only beta-blocker to have been shown effective in elderly heart failure patients, regardless of their left ventricular ejection fraction.
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Affiliation(s)
- Erik Lipsic
- University Medical Center Groningen, Thoraxcenter, Department of Cardiology, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
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Bosch M, Wensing M, Bakx JC, van der Weijden T, Hoes AW, Grol RPTM. Current treatment of chronic heart failure in primary care; still room for improvement. J Eval Clin Pract 2010; 16:644-50. [PMID: 20438610 DOI: 10.1111/j.1365-2753.2010.01455.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED RATIONAL AND AIMS: In recent years, guidelines for treatment of patients with chronic heart failure (CHF) have been updated. Insight in current pharmacological and non-pharmacological treatment of CHF in primary care, which was non-optimal in earlier studies, is limited. We aim to describe current pharmacological and non-pharmacological treatment of CHF in primary care. METHODS In this cross-sectional observational study, we included a representative sample of 357 patients diagnosed with CHF from 42 primary care practices in the Netherlands. We combined medical record data with data from patient and doctor questionnaires. RESULTS Mean age of patients was 75.7 years (SD 10.2), 53% were male, and 73% of patients had mild heart failure (New York Heart Association class I or II). 76.5% of patients received diuretics. Angiotensin-converting enzyme inhibitors were prescribed in 40.6% and angiotensin-II receptor blockers in 20.7%; beta-blockers were prescribed to 54.6%, while 24.9% received spironolactone. Patients with more severe heart failure had a lower probability of being treated according to guideline recommendations. Relevant lifestyle advice was given to 40-60% of the patients, depending on the specific lifestyle advice. CONCLUSIONS Implementation of evidence-based pharmacotherapy for heart failure in primary care has improved since clinical guidelines have been updated; especially with respect to prescription of beta-blockers. However, there still seems ample room for improvement, as in the case for providing lifestyle advice.
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Affiliation(s)
- Marije Bosch
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Logeart D, Solal AC. [Advantages of vasodilating beta-blockers in congestive heart failure]. Ann Cardiol Angeiol (Paris) 2010; 59:160-167. [PMID: 20620251 DOI: 10.1016/j.ancard.2010.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Beta-blockers play a pivotal role in the treatment of chronic systolic heart failure. However, the pharmacological family of beta-blockers is inhomogeneous regarding their pharmacological properties and their clinical effects can differ substantially according to different pharmacological properties. Because of vasodilator effects, the third generation of beta-blockers has additional potential across the cardiovascular diseases, from hypertension to heart failure. Nebivololol has both high selectivity for beta1-adrenergic receptors, no intrinsic sympathetic activity and ability to stimulate endothelial nitric oxide production. Such properties result in specific hemodynamic effects compared with others beta-blockers. Such properties also result in both high tolerability and positive metabolic effects which are crucial in high-risk groups. In the SENIORS trial, nebivolol demonstrated its efficacy and high tolerability in elderly patients with chronic heart failure irrespective of the left ventricular ejection fraction. More clinical trials would be useful to exhibit specific benefits of nebivolol in other high-risk groups of patients.
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Affiliation(s)
- D Logeart
- Hôpital Lariboisière, Service de Cardiologie, INSERM U942, 2 rue Ambroise Paré, 75010 Paris, France.
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Cohen-Solal A, Kotecha D, van Veldhuisen DJ, Babalis D, Böhm M, Coats AJ, Roughton M, Poole-Wilson P, Tavazzi L, Flather M. Efficacy and safety of nebivolol in elderly heart failure patients with impaired renal function: insights from the SENIORS trial. Eur J Heart Fail 2009; 11:872-80. [PMID: 19648605 PMCID: PMC2729679 DOI: 10.1093/eurjhf/hfp104] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM To determine the safety and efficacy of nebivolol in elderly heart failure (HF) patients with renal dysfunction. METHODS AND RESULTS SENIORS recruited patients aged 70 years or older with symptomatic HF, irrespective of ejection fraction, and randomized them to nebivolol or placebo. Patients (n = 2112) were divided by tertile of estimated glomerular filtration rate (eGFR). Mean age of patients was 76.1 years, 35% of patients had an ejection fraction of >35%, and 37% were women resulting in a unique cohort, far more representative of clinical practice than previous trials. eGFR was strongly associated with outcomes and nebivolol was similarly efficacious across eGFR tertiles. The primary outcome rate (all-cause mortality or cardiovascular hospital admission) and adjusted hazard ratio for nebivolol use in those with low eGFR was 40% and 0.84 (95% CI 0.67-1.07), 31% and 0.79 (0.60-1.04) in the middle tertile, and 29% and 0.86 (0.65-1.14) in the highest eGFR tertile. There was no interaction noted between renal function and the treatment effect (P = 0.442). Nebivolol use in patients with moderate renal impairment (eGFR <60) was not associated with major safety concerns, apart from higher rates of drug-discontinuation due to bradycardia. CONCLUSION Nebivolol is safe and has a similar effect in elderly HF patients with mild or moderate renal impairment.
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Affiliation(s)
- Alain Cohen-Solal
- Hôpital Lariboisiere, Assistance Publique-Hopitaux de Paris, Université Paris Diderot, INSERM U942, 2 Rue Ambroise Paré, 75475 Paris Cedex 10, France
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Rosenthal T, Nussinovitch N. Managing hypertension in the elderly in light of the changes during aging. Blood Press 2009; 17:186-94. [DOI: 10.1080/08037050802305578] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Talma Rosenthal
- Department of Physiology and Pharmacology, Hypertension Research Unit, Sackler School of Medicine, Tel Aviv University, Tel Aviv
| | - Naomi Nussinovitch
- Department of Medicine D, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
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van Veldhuisen DJ, de Boer RA. Low-dose digoxin in heart failure. Int J Cardiol 2009; 136:90-1; author reply 91-2. [DOI: 10.1016/j.ijcard.2008.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 04/01/2008] [Indexed: 11/16/2022]
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Beta-blockade with nebivolol in elderly heart failure patients with impaired and preserved left ventricular ejection fraction: Data From SENIORS (Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors With Heart Failure). J Am Coll Cardiol 2009; 53:2150-8. [PMID: 19497441 DOI: 10.1016/j.jacc.2009.02.046] [Citation(s) in RCA: 374] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 01/27/2009] [Accepted: 02/03/2009] [Indexed: 12/16/2022]
Abstract
OBJECTIVES In this pre-specified subanalysis of the SENIORS (Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors With Heart Failure) trial, which examined the effects of nebivolol in elderly heart failure (HF) patients, we explored the effects of left ventricular ejection fraction (EF) on outcomes, including the subgroups impaired EF (< or =35%) and preserved EF (>35%). BACKGROUND Beta-blockers are established drugs in patients with HF and impaired EF, but their value in preserved EF is unclear. METHODS We studied 2,111 patients; 1,359 (64%) had impaired (< or =35%) EF (mean 28.7%) and 752 (36%) had preserved (>35%) EF (mean 49.2%). The effect of nebivolol was investigated in these 2 groups, and it was compared to explore the interaction of EF with outcome. Follow-up was 21 months; the primary end point was all-cause mortality or cardiovascular hospitalizations. RESULTS Patients with preserved EF were more often women (49.9% vs. 29.8%) and had less advanced HF, more hypertension, and fewer prior myocardial infarctions (all p < 0.001). During follow-up, the primary end point occurred in 465 patients (34.2%) with impaired EF and in 235 patients (31.2%) with preserved EF. The effect of nebivolol on the primary end point (hazard ratio [HR] of nebivolol vs. placebo) was 0.86 (95% confidence interval: 0.72 to 1.04) in patients with impaired EF and 0.81 (95% confidence interval: 0.63 to 1.04) in preserved EF (p = 0.720 for subgroup interaction). Effects on all secondary end points were similar between groups (HR for all-cause mortality 0.84 and 0.91, respectively), and no p value for interaction was <0.48. CONCLUSIONS The effect of beta-blockade with nebivolol in elderly patients with HF in this study was similar in those with preserved and impaired EF.
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Armstrong PW, Alexander KP. Nebivolol in older adults with heart failure: reduced rates for seniors? J Am Coll Cardiol 2009; 53:2159-61. [PMID: 19497442 DOI: 10.1016/j.jacc.2009.03.019] [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: 02/23/2009] [Accepted: 03/03/2009] [Indexed: 11/16/2022]
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Cheng JWM. Nebivolol: a third-generation beta-blocker for hypertension. Clin Ther 2009; 31:447-62. [PMID: 19393838 DOI: 10.1016/j.clinthera.2009.03.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nebivolol is a third-generation beta(1)-selective beta-blocker that is approved for the treatment of hypertension. OBJECTIVE This article reviews the clinical pharmacology of nebivolol and its efficacy and safety profile in clinical studies of hypertension (the US Food and Drug Administration-approved indication) and heart failure (off-label use). METHODS Pertinent articles were identified through searches of MEDLINE and Current Contents from 1966 through December 15, 2008, using the terms nebivolol, drug interaction, pharmacokinetics, and pharmacology. The reference lists of the identified publications were reviewed for additional references. Abstracts presented at meetings of the American Heart Association and the American Society of Hypertension from 2006 through 2008 were also reviewed. All human clinical trials were included, regardless of design. RESULTS Twelve published clinical trials were identified that evaluated the use of nebivolol in the management of hypertension; 1 was placebo controlled, 1 was placebo and active controlled, and 10 involved direct comparisons with other antihypertensive agents. Nebivolol was reported to be as effective in lowering blood pressure (BP) as other beta-blockers (atenolol and bisoprolol), angiotensin-converting enzyme inhibitors (lisinopril and enalapril), the angiotensin-receptor blocker telmisartan, and calcium channel blockers (nifedipine and amlodipine). No published studies were identified that evaluated the effect of nebivolol on long-term cardiovascular outcomes. In data from a study in heart failure, nebivolol was associated with a 14% reduction in all-cause mortality and cardiovascular hospitalization at 12 months (P < 0.05). In comparative clinical studies, nebivolol appeared to be well tolerated relative to the other antihypertensive agents studied. The most commonly reported adverse events with nebivolol were fatigue (4%-79%), headache (2%-24%), paresthesia (7%-13%), bradycardia (6%-11%), rhinitis (1%-7%), and dizziness (2%-5%). Because of differences in its pharmacologic properties, nebivolol may have potential advantages in patients who are unable to tolerate traditional beta-blockers (eg, patients with asthma or chronic obstructive pulmonary disease, or men who experience erectile dysfunction while taking antihypertensive therapy). CONCLUSIONS Nebivolol is a cardioselective beta-blocker that has been reported to be efficacious and well tolerated for achieving BP control in patients with hypertension. Preliminary evidence suggests a potential for reduced mortality in patients with heart failure.
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Affiliation(s)
- Judy W M Cheng
- Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts 02115, USA.
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Baumhäkel M, Müller U, Böhm M. Influence of gender of physicians and patients on guideline-recommended treatment of chronic heart failure in a cross-sectional study. Eur J Heart Fail 2009; 11:299-303. [PMID: 19158153 DOI: 10.1093/eurjhf/hfn041] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Clinical outcomes of patients with chronic heart failure (CHF) have improved, but evidence-based treatment appears to be imbalanced depending on patients' and physicians' gender. We aimed to determine the interactions of gender with medical treatment of CHF. METHODS AND RESULTS Consecutive patients with CHF (n = 1857) were evaluated regarding co-morbidities, New York Heart Association classification, current medical treatment, and dosage of angiotensin-converting enzyme-inhibitors (ACE-Is) and beta-blockers. Gender of patients and treating physicians was recorded. Baseline characteristics of patients and physicians were comparable for males and females. Female patients were less frequently treated with ACE-Is, angiotensin-receptor blockers, or beta-blockers. Achieved doses were lower in female compared with male patients. Guideline-recommended drug use and achieved target doses tended to be higher in patients treated by female physicians. There was no different treatment for male or female patients by female physicians, whereas male physicians used significantly less medication and lower doses in female patients. In multivariable analysis, female gender of physicians was an independent predictor of use of beta-blockers. CONCLUSION Treatment of CHF is influenced by patients', but also physicians' gender with regard to evidenced-based drugs and their dosage. Physicians should be aware of this problem in order to avoid gender-related treatment imbalances.
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Affiliation(s)
- Magnus Baumhäkel
- Department of Cardiology, University Hospital of the Saarland, Kirrbergerstr. 1, 66421 Homburg/Saar, Germany.
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Shinde AA, Anderson AS. Treatment of hypertension in heart failure with preserved ejection fraction: role of the kidney. Heart Fail Clin 2008; 4:479-503. [PMID: 18760759 DOI: 10.1016/j.hfc.2008.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Heart failure can present clinically as primarily diastolic or systolic dysfunction or both. There is an increasing awareness that heart failure can occur in the presence of a normal left ventricular ejection fraction. Heart failure with normal left ventricular ejection fraction is frequently referred to as diastolic heart failure because of the presence of diastolic left ventricular dysfunction evident from impaired left ventricular relaxation. This article focuses on the treatment of hypertension and the role the kidney plays in selecting appropriate agents.
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Affiliation(s)
- Abhijit A Shinde
- University of Chicago, Department of Medicine, Chicago, IL 60637, USA.
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de Nigris F, Mancini FP, Balestrieri ML, Byrns R, Fiorito C, Williams-Ignarro S, Palagiano A, Crimi E, Ignarro LJ, Napoli C. Therapeutic dose of nebivolol, a nitric oxide-releasing β-blocker, reduces atherosclerosis in cholesterol-fed rabbits. Nitric Oxide 2008; 19:57-63. [DOI: 10.1016/j.niox.2008.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 03/12/2008] [Accepted: 03/27/2008] [Indexed: 10/22/2022]
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