Beta-blockers in asthma: myth and reality

Polypharmacy in older patients with asthma: hidden risks and opportunities for improvement

INTRODUCTION

Polypharmacy can be considered the norm in elderly patients, because older individuals experience an increasing number of concomitant respiratory and non-respiratory diseases other than asthma, carrying the risk of drug-to-drug-interactions and drug-to-comorbidities interactions. In this context, asthma in older adults, conventionally aging >65 years of age, cannot be adequately managed without considering their individual characteristics, as these challenge the traditional therapeutic algorithms/management strategies commonly applied to younger populations.

AREAS COVERED

The current article aims at addressing pitfalls and advantages of current pharmacological strategies in older individuals with asthma. Comorbidities become more common with increasing age and are also more frequent in adults with asthma than in those without it. Multiple medications are often needed to control asthma symptoms and prevent asthma exacerbations, and older patients with asthma may also take multiple medications for common comorbidities and complex health conditions, such as chronic cardiometabolic diseases. Polypharmacy is an emerging concern in the elderly population.

EXPERT OPINION

A patient-centered approach is crucial and polypharmacy in asthma requires careful management. A multidisciplinary approach will allow for a more holistic care and will ensure that all aspects of a patient's health are considered, optimizing medication management.

[Efficient patient preparation in computed tomography coronary angiography]

BACKGROUND

In the coming years, a significant increase in the number of computed tomography coronary angiographies (CCTA) is expected, leading to an additional burden on existing structures.

OBJECTIVES

Discussion of effective processes and patient preparation in the context of high-volume CCTA.

MATERIALS AND METHODS

The relevance of patient education and optimized workflows in clinical practice, including pharmacological heart rate control and vasodilation.

RESULTS

To conduct resource-efficient and effective patient examinations, comprehensive and clear patient education is crucial. This can be provided to the patient during scheduling or delivered digitally, so that the patient arrives with a thorough understanding of the examination process. In addition, targeted optimization of workflows tailored to CCTA is important. For high image quality, the administration of β‑blockers is necessary in most cases. This can be done intravenously to save time. The administration of nitrates immediately before the examination is recommended by current guidelines for all patients without contraindications and is ideally applied sublingually shortly before the examination.

CONCLUSION

The anticipated increase in CCTA will significantly strain existing structures not only in terms of reporting. Especially standardized and structured workflows pre- and periprocedurally are essential for handling a high number of examinations, while maintaining sufficient image quality in clinical practice.

Supraventricular tachycardia diagnosis in asthma patients is associated with adverse health outcomes

INTRODUCTION

Supraventricular tachycardia (SVT) can occur during treatment of an acute asthma exacerbation. There are, however, no data on the long-term outcomes of children who are diagnosed with both asthma and SVT. This study aims to analyze the impact of SVT in asthmatic children on mortality and/or cardiac arrest, hypothesizing asthmatic subjects with SVT have increased mortality and/or cardiac arrest compared to asthmatic subject with no-SVT.

METHODS

This was a retrospective cohort study, utilizing the TriNetX© electronic health record (EHR) database that included asthmatic subjects 2-18 years of age. The study population was divided into two groups (subjects with SVT diagnosis and no-SVT diagnosis). Data related to demographics, diagnostic, procedural, and medication codes were collected. The primary outcome was any death and/or cardiac arrest in a patient after the first asthma diagnosis date.

RESULTS

This study included 91,066 asthmatic subjects (244 [0.27%] with SVT and 90,822 [99.73%] with no-SVT). Multivariable logistic regression analysis demonstrated that after controlling for demographic and clinical features, the odds of all-cause death and/or cardiac arrest after the first reported asthma exacerbation was significantly higher in asthmatic children with SVT compared to no-SVT (odds ratio [OR]: 4.30, confidence interval [CI]: 2.50-7.39, p < .001).

CONCLUSIONS

Our large nationwide EHR study suggests that asthmatic pediatric patients with documented SVT diagnosis at any point in their EHR may be at increased risk of adverse health outcomes compared to no-SVT. Further studies are needed to determine the factors contributing to the increased risk of mortality and/or cardiac arrest in children with asthma and SVT.

β-Blockers and Asthma: Surprising findings from the FAERS database

INTRODUCTION

β-Blockers are essential for cardiovascular disease management but can induce respiratory issues, particularly with non-selective β-blockers. Their safety in asthmatic patients is debated.

OBJECTIVE

This study investigates the link between different classes of β-blockers and the risk of asthma and asthma-like adverse events (AEs) using data from the Food and Drug Administration's Adverse Event Reporting System (FAERS).

METHODS

β-Blockers were first reviewed according to European Society of Cardiology classification and then using the Vashistha and Kumar classification. The risk associated with different β-blocker classes was evaluated through disproportionality analysis using the reporting odds ratio (ROR).

RESULTS

Among 251,145 AEs reported for β-blockers, 4104 were asthma-related. Selective β1-blockers had a higher asthma risk signal (ROR: 1.15) compared to non-selective β-blockers (ROR: 0.90). α- and β-Blockers showed the lowest risk (ROR: 0.51). The Vashistha and Kumar classification detailed risk profiles for various β-blockers, highlighting differences even within the same class. Dual α- and β-blockers, hydrophilic, and lipophilic β-blockers posed lower asthma risks, while selective β1-blockers had higher risks regardless of intrinsic sympathomimetic activity.

CONCLUSION

Although the signals detected by disproportionality analysis are only candidate risks, the risk stratification resulting from our analysis highlights the need for cautious β-blocker selection in asthmatic patients or those predisposed to asthma. Furthermore, despite the limitations associated with the FAERS data, the study reveals significant variability in risk among different β-blocker classes, crucial for clinical decisions and patient management. Drugs like esmolol, metoprolol, nebivolol, and nadolol may be safer for asthmatic patients, whereas betaxolol, bisoprolol, timolol, and propranolol should be avoided.

Calcium channel blockers and beta blockers in pediatric supraventricular tachycardia

INTRODUCTION

Supraventricular tachycardia (SVT) is a common pediatric arrhythmia. Beta blockers (BBs) and calcium channel blockers (CCBs) are used for treatment despite little data examining their use. We describe the prescriptive tendencies, efficacy, and tolerability of BBs and CCBs used in the treatment of pediatric SVT.

METHODS AND RESULTS

This is a multicenter retrospective cohort study from three academic children's hospitals. Individuals aged 1-21 years at time of SVT diagnosis initiated on a BB or a CCB between 01/01/2010 and 12/31/2020 were included. Exclusion criteria were pre-excitation, ectopic atrial tachycardia, and hemodynamically significant heart disease. Demographic, comorbidity, symptomatology, and medication data were collected. Treatment success was defined using a composite data abstraction tool. Of 164 patients, 151 received a BB and 13 received a CCB. The success rate on the initial dosage was 46% for both BB and CCB; the success rate following dosage adjustments was also comparable for BBs (98/151, 65%) and CCBs (9/13, 69%). While 27 (18%) BB patients experienced intolerable side effects, no CCB patient did.

CONCLUSION

Treatment with a BB or CCB was successful in half of patients. BBs were prescribed more frequently than CCBs but were associated with more side effects.

Asthma and Cardiovascular Diseases: Navigating Mutual Pharmacological Interferences

Asthma and cardiovascular disease (CVD) often co-exist. When a patient has both conditions, management requires an approach that addresses the unique challenges of each condition separately, while also considering their potential interactions. However, specific guidance on the management of asthma in patients with CVD and on the management of CVD in patients with asthma is still lacking. Nevertheless, health care providers need to adopt a comprehensive approach that includes both respiratory and CVD health. The management of CVD in patients with asthma requires a delicate balance between controlling respiratory symptoms and minimising potential cardiovascular (CV) risks. In the absence of specific guidelines for the management of patients with both conditions, the most prudent approach would be to follow established guidelines for each condition independently. Careful selection of asthma medications is essential to avoid exacerbation of CV symptoms. In addition, optimal management of CV risk factors is essential. However, close monitoring of these patients is important as there is evidence that some asthma medications may have adverse effects on CVD and, conversely, that some CVD medications may worsen asthma symptoms. On the other hand, there is also increasing evidence of the potential beneficial effects of asthma medications on CVD and, conversely, that some CVD medications may reduce the severity of asthma symptoms. We aim to elucidate the potential risks and benefits associated with the use of asthma medications in patients with CVD, and the potential pulmonary risks and benefits for patients with asthma who are prescribed CVD medications.

Role of β-blockers in Preventing Heart Failure and Major Adverse Cardiac Events Post Myocardial Infarction

β-blockers have been widely utilized as a part of acute myocardial infarction (AMI) treatment for the past 40 years. Patients receiving β-adrenergic blockers for an extended period following myocardial infarction have a higher chance of surviving. Although many patients benefited from β-blockers, many do not, including those with myocardial infarction, left ventricle dysfunction, chronic pulmonary disease, and elderly people. In individuals with the post-acute coronary syndrome and normal left ventricular ejection fraction (LVEF), the appropriate duration of betablocker therapy is still unknown. There is also no time limit for those without angina and those who do not need β-blockers for arrhythmia or hypertension. Interestingly, β-blockers have been prescribed for more than four decades. The novel mechanism of action on cellular compartments has been found continually, which opens a new way for their potential application in cardiac failure and other cardiac events like post-myocardial infarction. Here, in this review, we studied β-blocker usage in these circumstances and the current recommendations for β-blocker use from clinical practice guidelines.

Drug Safety in Episodic Migraine Management in Adults. Part 2: Preventive Treatments

PURPOSE OF REVIEW

The aim of this review is to aid in decision-making when choosing safe and effective options for preventive migraine medications.

RECENT FINDINGS

In Part 2, we have compiled clinically relevant safety considerations for commonly used migraine prophylactic treatments. Preventive treatment of episodic migraine includes nonspecific and migraine-specific drugs. While medications from several pharmacological classes-such as anticonvulsants, beta-blockers, and antidepressants-have an established efficacy in migraine prevention, they are associated with a number of side effects. The safety of migraine-specific treatments such as anti-CGRP monoclonal antibodies and gepants are also discussed. This review highlights safety concerns of commonly used migraine prophylactic agents and offers suggestions on how to mitigate those risks.

Association Between Asthma and Migraine: A Systematic Review and Meta-Analysis of Observational Studies

Objectives: The purpose of this study was to determine the association between asthma and migraine and assess the risk for migraine in patients with asthma.

Methods: We systematically searched the Cochrane Library, PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) databases from inception to September 26, 2021, for indexed observational studies that examined either the odds or risk of migraine in subjects with asthma. The qualities of the included studies were evaluated using the Newcastle–Ottawa Scale. A random-effects meta-analysis was performed to calculate the odds ratio for case-control and cross-sectional studies and the risk ratio for cohort studies.

Results: Seven observational studies (four cross-sectional and three cohort studies) with a total of 549,534 study subjects were included in this systematic review and meta-analysis and selected for data extraction. Four articles were considered to be of moderate quality; other studies were considered to be of high quality. Asthma was associated with increased odds (OR, 1.85; 95%CI, 1.39–2.45) and risk of migraine (RR, 1.70; 95%CI, 1.52–1.90).

Conclusions: The available evidence that supports the existence of an association between asthma and migraine is limited. Clinicians should be aware that patients with asthma show both increased prevalence and incidence of migraine. Further studies are warranted to further clarify the relationship between asthma and migraine.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=185881, identifier: CRD42020185881.

Effect of long-term beta-blocker treatment following myocardial infarction among stable, optimally treated patients without heart failure in the reperfusion era: a Danish, nationwide cohort study

AIMS

We aimed to investigate the long-term cardio-protective effect associated with beta-blocker (BB) treatment in stable, optimally treated myocardial infarction (MI) patients without heart failure (HF).

METHODS AND RESULTS

Using nationwide registries, we included patients with first-time MI undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) during admission and treated with both acetyl-salicylic acid and statins post-discharge between 2003 and 2018. Patients with prior history of MI, prior BB use, or any alternative indication or contraindication for BB treatment were excluded. Follow-up began 3 months following discharge in patients alive, free of cardiovascular (CV) events or procedures. Primary outcomes were CV death, recurrent MI, and a composite outcome of CV events. We used adjusted logistic regression and reported standardized absolute risks and differences (ARD) 3 years after MI. Overall, 30 177 stable, optimally treated MI patients were included (58% acute PCI, 26% sub-acute PCI, 16% CAG without intervention). At baseline, 82% of patients were on BB treatment (median age 61 years, 75% male) and 18% were not (median age 62 years, 68% male). BB treatment was associated with a similar risk of CV death, recurrent MI, and the composite outcome of CV events compared with no BB treatment [ARD (95% confidence intervals)] correspondingly; 0.1% (-0.3% to 0.5%), 0.2% (-0.7% to 1.2%), and 1.2% (-0.2% to 2.7%).

CONCLUSIONS

In this nationwide cohort study of stable, optimally treated MI patients without HF, we found no long-term effect of BB treatment on CV prognosis following the patients from 3 months to 3 years after MI admission.

Adrenergic signalling in osteoarthritis

Adrenoceptors (ARs) mediate the effects of the sympathetic neurotransmitters norepinephrine (NE) and epinephrine (E) in the human body and play a central role in physiologic and pathologic processes. Therefore, ARs have long been recognized as targets for therapeutic agents, especially in the field of cardiovascular medicine. During the past decades, the contribution of the sympathetic nervous system (SNS) and particularly of its major peripheral catecholamine NE to the pathogenesis of osteoarthritis (OA) attracted growing interest. OA is the most common degenerative joint disorder worldwide and a disease of the whole joint. It is characterized by progressive degradation of articular cartilage, synovial inflammation, osteophyte formation, and subchondral bone sclerosis mostly resulting in chronic pain. The subchondral bone marrow, the periosteum, the synovium, the vascular meniscus and numerous tendons and ligaments are innervated by tyrosine hydroxylase-positive (TH+) sympathetic nerve fibers that release NE into the synovial fluid and cells of all abovementioned joint tissues express at least one out of nine AR subtypes. During the past decades, several in vitro studies explored the AR-mediated effects of NE on different cell types in the joint. So far, only a few studies used animal OA models to investigate the contribution of distinct AR subtypes to OA pathogenesis in vivo. This narrative review shortly summarizes the current background knowledge about ARs and their signalling pathways at first. In the second part, we focus on recent findings in the field of NE-induced AR-mediated signalling in different joint tissues during OA pathogenesis and at the end, we will delineate the potential of targeting the adrenergic signalling for OA prevention or treatment. We used the PubMed bibliographic database to search for keywords such as 'joint' or 'cartilage' or 'synovium' or 'bone' and 'osteoarthritis' and/or 'trauma' and 'sympathetic nerve fibers' and/or 'norepinephrine' and 'adrenergic receptors / adrenoceptors' as well as 'adrenergic therapy'.

Hypertension Drug Therapy

Hypertension is still the number one global killer. No matter what causes are, lowering blood pressure can significantly reduce cardiovascular complications, cardiovascular death, and total death. Unfortunately, some hypertensive individuals simply do not know having hypertension. Some knew it but either not being treated or treated but blood pressure does not achieve goal. The reasons for inadequate control of blood pressure are many. One important reason is that we are not very familiar with antihypertensive agents and less attention has been paid to comorbidities, complications as well as the hypertension-modified target organ damage in patients with hypertension. The right antihypertensive drug was not given to the right hypertensive patients at right time. This reviewer studied comprehensively the literature, hopefully that the review will help improve antihypertensive drug selection and antihypertensive therapy.