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Johri N, Matreja PS, Maurya A, Varshney S, Smritigandha. Role of β-blockers in Preventing Heart Failure and Major Adverse Cardiac Events Post Myocardial Infarction. Curr Cardiol Rev 2023; 19:e110123212591. [PMID: 36635926 PMCID: PMC10494272 DOI: 10.2174/1573403x19666230111143901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Nishant Johri
- Department of Pharmacy Practice, Teerthanker Mahaveer College of Pharmacy, Moradabad, Uttar Pradesh, India
| | - Prithpal S. Matreja
- Department of Pharmacology, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
| | - Aditya Maurya
- Department of Pharmacy Practice, Teerthanker Mahaveer College of Pharmacy, Moradabad, Uttar Pradesh, India
| | - Shivani Varshney
- Department of Pharmacy Practice, Teerthanker Mahaveer College of Pharmacy, Moradabad, Uttar Pradesh, India
| | - Smritigandha
- Department of Pharmacy Practice, Teerthanker Mahaveer College of Pharmacy, Moradabad, Uttar Pradesh, India
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Karwath A, Bunting KV, Gill SK, Tica O, Pendleton S, Aziz F, Barsky AD, Chernbumroong S, Duan J, Mobley AR, Cardoso VR, Slater K, Williams JA, Bruce EJ, Wang X, Flather MD, Coats AJS, Gkoutos GV, Kotecha D. Redefining β-blocker response in heart failure patients with sinus rhythm and atrial fibrillation: a machine learning cluster analysis. Lancet 2021; 398:1427-1435. [PMID: 34474011 PMCID: PMC8542730 DOI: 10.1016/s0140-6736(21)01638-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/01/2021] [Accepted: 07/07/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Mortality remains unacceptably high in patients with heart failure and reduced left ventricular ejection fraction (LVEF) despite advances in therapeutics. We hypothesised that a novel artificial intelligence approach could better assess multiple and higher-dimension interactions of comorbidities, and define clusters of β-blocker efficacy in patients with sinus rhythm and atrial fibrillation. METHODS Neural network-based variational autoencoders and hierarchical clustering were applied to pooled individual patient data from nine double-blind, randomised, placebo-controlled trials of β blockers. All-cause mortality during median 1·3 years of follow-up was assessed by intention to treat, stratified by electrocardiographic heart rhythm. The number of clusters and dimensions was determined objectively, with results validated using a leave-one-trial-out approach. This study was prospectively registered with ClinicalTrials.gov (NCT00832442) and the PROSPERO database of systematic reviews (CRD42014010012). FINDINGS 15 659 patients with heart failure and LVEF of less than 50% were included, with median age 65 years (IQR 56-72) and LVEF 27% (IQR 21-33). 3708 (24%) patients were women. In sinus rhythm (n=12 822), most clusters demonstrated a consistent overall mortality benefit from β blockers, with odds ratios (ORs) ranging from 0·54 to 0·74. One cluster in sinus rhythm of older patients with less severe symptoms showed no significant efficacy (OR 0·86, 95% CI 0·67-1·10; p=0·22). In atrial fibrillation (n=2837), four of five clusters were consistent with the overall neutral effect of β blockers versus placebo (OR 0·92, 0·77-1·10; p=0·37). One cluster of younger atrial fibrillation patients at lower mortality risk but similar LVEF to average had a statistically significant reduction in mortality with β blockers (OR 0·57, 0·35-0·93; p=0·023). The robustness and consistency of clustering was confirmed for all models (p<0·0001 vs random), and cluster membership was externally validated across the nine independent trials. INTERPRETATION An artificial intelligence-based clustering approach was able to distinguish prognostic response from β blockers in patients with heart failure and reduced LVEF. This included patients in sinus rhythm with suboptimal efficacy, as well as a cluster of patients with atrial fibrillation where β blockers did reduce mortality. FUNDING Medical Research Council, UK, and EU/EFPIA Innovative Medicines Initiative BigData@Heart.
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Affiliation(s)
- Andreas Karwath
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - Karina V Bunting
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - Simrat K Gill
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Otilia Tica
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - Samantha Pendleton
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Furqan Aziz
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - Andrey D Barsky
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | | | - Jinming Duan
- Computer Sciences, University of Birmingham, Birmingham, UK
| | - Alastair R Mobley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - Victor Roth Cardoso
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - Karin Slater
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - John A Williams
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - Emma-Jane Bruce
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | - Xiaoxia Wang
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK
| | | | | | - Georgios V Gkoutos
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK.
| | - Dipak Kotecha
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; Health Data Research UK Midlands Site, Birmingham, UK.
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Ziff OJ, Samra M, Howard JP, Bromage DI, Ruschitzka F, Francis DP, Kotecha D. Beta-blocker efficacy across different cardiovascular indications: an umbrella review and meta-analytic assessment. BMC Med 2020; 18:103. [PMID: 32366251 PMCID: PMC7199339 DOI: 10.1186/s12916-020-01564-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/17/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Beta-blockers are widely used for many cardiovascular conditions; however, their efficacy in contemporary clinical practice remains uncertain. METHODS We performed a prospectively designed, umbrella review of meta-analyses of randomised controlled trials (RCTs) investigating the evidence of beta-blockers in the contemporary management of coronary artery disease (CAD), heart failure (HF), patients undergoing surgery or hypertension (registration: PROSPERO CRD42016038375). We searched MEDLINE, EMBASE and the Cochrane Library from inception until December 2018. Outcomes were analysed as beta-blockers versus control for all-cause mortality, myocardial infarction (MI), incident HF or stroke. Two independent investigators abstracted the data, assessed the quality of the evidence and rated the certainty of evidence. RESULTS We identified 98 meta-analyses, including 284 unique RCTs and 1,617,523 patient-years of follow-up. In CAD, 12 meta-analyses (93 RCTs, 103,481 patients) showed that beta-blockers reduced mortality in analyses before routine reperfusion, but there was a lack of benefit in contemporary studies where ≥ 50% of patients received thrombolytics or intervention. Beta-blockers reduced incident MI at the expense of increased HF. In HF with reduced ejection fraction, 34 meta-analyses (66 RCTs, 35,383 patients) demonstrated a reduction in mortality and HF hospitalisation with beta-blockers in sinus rhythm, but not in atrial fibrillation. In patients undergoing surgery, 23 meta-analyses (89 RCTs, 19,211 patients) showed no effect of beta-blockers on mortality for cardiac surgery, but increased mortality in non-cardiac surgery. In non-cardiac surgery, beta-blockers reduced MI after surgery but increased the risk of stroke. In hypertension, 27 meta-analyses (36 RCTs, 260,549 patients) identified no benefit versus placebo, but beta-blockers were inferior to other agents for preventing mortality and stroke. CONCLUSIONS Beta-blockers substantially reduce mortality in HF patients in sinus rhythm, but for other conditions, clinicians need to weigh up both benefit and potential risk.
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Affiliation(s)
- Oliver J Ziff
- University of Birmingham Institute of Cardiovascular Sciences, Medical School, Birmingham, B15 2TT, UK.,University College London, London, WC1E 6BT, UK
| | | | | | - Daniel I Bromage
- University College London, London, WC1E 6BT, UK.,Kings College London, London, WC2R 2LS, UK
| | | | | | - Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, Medical School, Birmingham, B15 2TT, UK. .,Monash Centre of Cardiovascular Research & Education in Therapeutics, Monash University, Melbourne, Victoria, 3004, Australia. .,University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Institute of Translational Medicine, Birmingham, B15 2GW, UK.
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Kotecha D, Gill SK, Flather MD, Holmes J, Packer M, Rosano G, Böhm M, McMurray JJV, Wikstrand J, Anker SD, van Veldhuisen DJ, Manzano L, von Lueder TG, Rigby AS, Andersson B, Kjekshus J, Wedel H, Ruschitzka F, Cleland JGF, Damman K, Redon J, Coats AJS. Impact of Renal Impairment on Beta-Blocker Efficacy in Patients With Heart Failure. J Am Coll Cardiol 2019; 74:2893-2904. [PMID: 31806133 DOI: 10.1016/j.jacc.2019.09.059] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/11/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Moderate and moderately severe renal impairment are common in patients with heart failure and reduced ejection fraction, but whether beta-blockers are effective is unclear, leading to underuse of life-saving therapy. OBJECTIVES This study sought to investigate patient prognosis and the efficacy of beta-blockers according to renal function using estimated glomerular filtration rate (eGFR). METHODS Analysis of 16,740 individual patients with left ventricular ejection fraction <50% from 10 double-blind, placebo-controlled trials was performed. The authors report all-cause mortality on an intention-to-treat basis, adjusted for baseline covariates and stratified by heart rhythm. RESULTS Median eGFR at baseline was 63 (interquartile range: 50 to 77) ml/min/1.73 m2; 4,584 patients (27.4%) had eGFR 45 to 59 ml/min/1.73 m2, and 2,286 (13.7%) 30 to 44 ml/min/1.73 m2. Over a median follow-up of 1.3 years, eGFR was independently associated with mortality, with a 12% higher risk of death for every 10 ml/min/1.73 m2 lower eGFR (95% confidence interval [CI]: 10% to 15%; p < 0.001). In 13,861 patients in sinus rhythm, beta-blockers reduced mortality versus placebo; adjusted hazard ratio (HR): 0.73 for eGFR 45 to 59 ml/min/1.73 m2 (95% CI: 0.62 to 0.86; p < 0.001) and 0.71 for eGFR 30 to 44 ml/min/1.73 m2 (95% CI: 0.58 to 0.87; p = 0.001). The authors observed no deterioration in renal function over time in patients with moderate or moderately severe renal impairment, no difference in adverse events comparing beta-blockers with placebo, and higher mortality in patients with worsening renal function on follow-up. Due to exclusion criteria, there were insufficient patients with severe renal dysfunction (eGFR <30 ml/min/1.73 m2) to draw conclusions. In 2,879 patients with atrial fibrillation, there was no reduction in mortality with beta-blockers at any level of eGFR. CONCLUSIONS Patients with heart failure, left ventricular ejection fraction <50% and sinus rhythm should receive beta-blocker therapy even with moderate or moderately severe renal dysfunction.
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Affiliation(s)
- Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia.
| | - Simrat K Gill
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Marcus D Flather
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich, United Kingdom
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Giuseppe Rosano
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - Michael Böhm
- Kardiologie, Angiologie und Internistische Intensivmedizin, Universitatsklinikum des Saarlandes, Homburg/Saar, Germany
| | - John J V McMurray
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, United Kingdom
| | - John Wikstrand
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Stefan D Anker
- Department of Cardiology, Charite Campus Virchow-Klinikum, Berlin, Germany
| | - Dirk J van Veldhuisen
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, RB Groningen, the Netherlands
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá (IRYCIS), Plaza de San Diego, Madrid, Spain
| | - 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
- Hull York Medical School, Faculty of Health Sciences, University of Hull, Kingston-upon-Hull, United Kingdom
| | - Bert Andersson
- 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
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Frank Ruschitzka
- Klinik fur Kardiologie, UniversitätsSpital Zürich, Zürich, Switzerland
| | - John G F Cleland
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, RB Groningen, the Netherlands
| | - Josep Redon
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Andrew J S Coats
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
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Cleland JGF, Bunting KV, Flather MD, Altman DG, Holmes J, Coats AJS, Manzano L, McMurray JJV, Ruschitzka F, van Veldhuisen DJ, von Lueder TG, Böhm M, Andersson B, Kjekshus J, Packer M, Rigby AS, Rosano G, Wedel H, Hjalmarson Å, Wikstrand J, Kotecha D. Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials. Eur Heart J 2018; 39:26-35. [PMID: 29040525 PMCID: PMC5837435 DOI: 10.1093/eurheartj/ehx564] [Citation(s) in RCA: 394] [Impact Index Per Article: 65.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/17/2017] [Accepted: 09/17/2017] [Indexed: 12/15/2022] Open
Abstract
Aims Recent guidelines recommend that patients with heart failure and left ventricular ejection fraction (LVEF) 40-49% should be managed similar to LVEF ≥ 50%. We investigated the effect of beta-blockers according to LVEF in double-blind, randomized, placebo-controlled trials. Methods and results Individual patient data meta-analysis of 11 trials, stratified by baseline LVEF and heart rhythm (Clinicaltrials.gov: NCT0083244; PROSPERO: CRD42014010012). Primary outcomes were all-cause mortality and cardiovascular death over 1.3 years median follow-up, with an intention-to-treat analysis. For 14 262 patients in sinus rhythm, median LVEF was 27% (interquartile range 21-33%), including 575 patients with LVEF 40-49% and 244 ≥ 50%. Beta-blockers reduced all-cause and cardiovascular mortality compared to placebo in sinus rhythm, an effect that was consistent across LVEF strata, except for those in the small subgroup with LVEF ≥ 50%. For LVEF 40-49%, death occurred in 21/292 [7.2%] randomized to beta-blockers compared to 35/283 [12.4%] with placebo; adjusted hazard ratio (HR) 0.59 [95% confidence interval (CI) 0.34-1.03]. Cardiovascular death occurred in 13/292 [4.5%] with beta-blockers and 26/283 [9.2%] with placebo; adjusted HR 0.48 (95% CI 0.24-0.97). Over a median of 1.0 years following randomization (n = 4601), LVEF increased with beta-blockers in all groups in sinus rhythm except LVEF ≥50%. For patients in atrial fibrillation at baseline (n = 3050), beta-blockers increased LVEF when < 50% at baseline, but did not improve prognosis. Conclusion Beta-blockers improve LVEF and prognosis for patients with heart failure in sinus rhythm with a reduced LVEF. The data are most robust for LVEF < 40%, but similar benefit was observed in the subgroup of patients with LVEF 40-49%.
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Affiliation(s)
- John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Karina V Bunting
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham B15 2TT, UK
| | - Marcus D Flather
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich NR4 7TJ, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX1 2JD, UK
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX1 2JD, UK
| | - Andrew J S Coats
- San Raffaele Pisana Scientific Institute, Via della Pisana, 235, 00163 Rome, Italy
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá (IRYCIS), Plaza de San Diego, 28801 Alcalá de Henares, Madrid, Spain
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Frank Ruschitzka
- Klinik für Kardiologie, UniversitätsSpital Zürich, Universitätstrasse 8, 8006 Zürich, Switzerland
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, PO box 30.001 9700 RB Groningen, The Netherlands
| | - Thomas G von Lueder
- Department of Cardiology, Oslo University Hospital, PO Box 4950 Nydalen N-0424 Oslo, Norway
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Michael Böhm
- Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 100, 66421 Homburg/Saar, Germany
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska University Hospital and Gothenburg University, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - John Kjekshus
- Rikshospitalet University Hospital and Faculty of Medicine, University of Oslo, Problemveien 7, 0315 Oslo, Norway
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, 621 Hall St, Dallas TX 75226, USA
| | - Alan S Rigby
- Hull York Medical School, Faculty of Health Sciences, University of Hull, Kingston-upon-Hull, HU6 7RX, UK
| | - Giuseppe Rosano
- Cardiovascular and Cell Science Institute, St George’s University of London, SW17 0RE, UK
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Roma, Italy
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Box 100, S-405 30 Gothenburg, Sweden
| | - Åke Hjalmarson
- Department of Cardiology, Sahlgrenska University Hospital and Gothenburg University, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - John Wikstrand
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Bruna Stråket 16, 413 45 Gothenburg, Sweden
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham B15 2TT, UK
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
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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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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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8
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Kotecha D, Manzano L, Krum H, Rosano G, Holmes J, Altman DG, Collins PD, Packer M, Wikstrand J, Coats AJS, Cleland JGF, Kirchhof P, von Lueder TG, Rigby AS, Andersson B, Lip GYH, van Veldhuisen DJ, Shibata MC, Wedel H, Böhm M, Flather MD. Effect of age and sex on efficacy and tolerability of β blockers in patients with heart failure with reduced ejection fraction: individual patient data meta-analysis. BMJ 2016; 353:i1855. [PMID: 27098105 PMCID: PMC4849174 DOI: 10.1136/bmj.i1855] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the efficacy and tolerability of β blockers in a broad age range of women and men with heart failure with reduced ejection fraction (HFrEF) by pooling individual patient data from placebo controlled randomised trials. DESIGN Prospectively designed meta-analysis of individual patient data from patients aged 40-85 in sinus rhythm at baseline, with left ventricular ejection fraction <0.45. PARTICIPANTS 13,833 patients from 11 trials; median age 64; 24% women. MAIN OUTCOME MEASURES The primary outcome was all cause mortality; the major secondary outcome was admission to hospital for heart failure. Analysis was by intention to treat with an adjusted one stage Cox proportional hazards model. RESULTS Compared with placebo, β blockers were effective in reducing mortality across all ages: hazard ratios were 0.66 (95% confidence interval 0.53 to 0.83) for the first quarter of age distribution (median age 50); 0.71 (0.58 to 0.87) for the second quarter (median age 60); 0.65 (0.53 to 0.78) for the third quarter (median age 68); and 0.77 (0.64 to 0.92) for the fourth quarter (median age 75). There was no significant interaction when age was modelled continuously (P=0.1), and the absolute reduction in mortality was 4.3% over a median follow-up of 1.3 years (number needed to treat 23). Admission to hospital for heart failure was significantly reduced by β blockers, although this effect was attenuated at older ages (interaction P=0.05). There was no evidence of an interaction between treatment effect and sex in any age group. Drug discontinuation was similar regardless of treatment allocation, age, or sex (14.4% in those give β blockers, 15.6% in those receiving placebo). CONCLUSION Irrespective of age or sex, patients with HFrEF in sinus rhythm should receive β blockers to reduce the risk of death and admission to hospital.Registration PROSPERO CRD42014010012; Clinicaltrials.gov NCT00832442.
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Affiliation(s)
- Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy Cardiovascular and Cell Science Institute, St George's University of London, London, UK
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Peter D Collins
- National Heart and Lung Institute, Imperial College, London, UK
| | | | - John Wikstrand
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Andrew J S Coats
- Monash Warwick Alliance, Monash University, Melbourne, Australia Monash Warwick Alliance, University of Warwick, Warwick, UK
| | | | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | | | - Alan S Rigby
- Academic Cardiology, Castle Hill Hospital, Kingston upon Hull, UK
| | - Bert Andersson
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | | | - Hans Wedel
- Nordic School of Public Health, Gothenburg, Sweden
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
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9
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Abstract
End under-prescribing for women and older adults
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Affiliation(s)
- Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Netherlands
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10
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Kotecha D, Chudasama R, Lane DA, Kirchhof P, Lip GY. Atrial fibrillation and heart failure due to reduced versus preserved ejection fraction: A systematic review and meta-analysis of death and adverse outcomes. Int J Cardiol 2016; 203:660-6. [DOI: 10.1016/j.ijcard.2015.10.220] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/27/2015] [Indexed: 11/30/2022]
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11
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Kotecha D, Piccini JP. Atrial fibrillation in heart failure: what should we do? Eur Heart J 2015; 36:3250-7. [PMID: 26419625 PMCID: PMC4670966 DOI: 10.1093/eurheartj/ehv513] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/25/2015] [Accepted: 09/07/2015] [Indexed: 01/06/2023] Open
Abstract
Heart failure (HF) and atrial fibrillation (AF) are two conditions that are likely to dominate the next 50 years of cardiovascular (CV) care. Both are increasingly prevalent and associated with high morbidity, mortality, and healthcare cost. They are closely inter-related with similar risk factors and shared pathophysiology. Patients with concomitant HF and AF suffer from even worse symptoms and poorer prognosis, yet evidence-based evaluation and management of this group of patients is lacking. In this review, we evaluate the common mechanisms for the development of AF in HF patients and vice versa, focusing on the evidence for potential treatment strategies. Recent data have suggested that these patients may respond differently than those with HF or AF alone. These results highlight the clear clinical need to identify and treat according to best evidence, in order to prevent adverse outcomes and reduce the huge burden that HF and AF are expected to have on global healthcare systems in the future. We propose an easy-to-use clinical mnemonic to aid the initial management of newly discovered concomitant HF and AF, the CAN-TREAT HFrEF + AF algorithm (Cardioversion if compromised; Anticoagulation unless contraindication; Normalize fluid balance; Target initial heart rate <110 b.p.m.; Renin-angiotensin-aldosterone modification; Early consideration of rhythm control; Advanced HF therapies; Treatment of other CV disease).
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Affiliation(s)
- Dipak Kotecha
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK Monash Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Clinical Cardiac Electrophysiology, Duke University Medical Center, Durham, USA
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12
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Ziff OJ, Lane DA, Samra M, Griffith M, Kirchhof P, Lip GYH, Steeds RP, Townend J, Kotecha D. Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data. BMJ 2015; 351:h4451. [PMID: 26321114 PMCID: PMC4553205 DOI: 10.1136/bmj.h4451] [Citation(s) in RCA: 210] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To clarify the impact of digoxin on death and clinical outcomes across all observational and randomised controlled trials, accounting for study designs and methods. DATA SOURCES AND STUDY SELECTION Comprehensive literature search of Medline, Embase, the Cochrane Library, reference lists, and ongoing studies according to a prospectively registered design ( PROSPERO CRD42014010783), including all studies published from 1960 to July 2014 that examined treatment with digoxin compared with control (placebo or no treatment). DATA EXTRACTION AND SYNTHESIS Unadjusted and adjusted data pooled according to study design, analysis method, and risk of bias. MAIN OUTCOME MEASURES Primary outcome (all cause mortality) and secondary outcomes (including admission to hospital) were meta-analysed with random effects modelling. RESULTS 52 studies were systematically reviewed, comprising 621,845 patients. Digoxin users were 2.4 years older than control (weighted difference 95% confidence interval 1.3 to 3.6), with lower ejection fraction (33% v 42%), more diabetes, and greater use of diuretics and anti-arrhythmic drugs. Meta-analysis included 75 study analyses, with a combined total of 4,006,210 patient years of follow-up. Compared with control, the pooled risk ratio for death with digoxin was 1.76 in unadjusted analyses (1.57 to 1.97), 1.61 in adjusted analyses (1.31 to 1.97), 1.18 in propensity matched studies (1.09 to 1.26), and 0.99 in randomised controlled trials (0.93 to 1.05). Meta-regression confirmed that baseline differences between treatment groups had a significant impact on mortality associated with digoxin, including markers of heart failure severity such as use of diuretics (P=0.004). Studies with better methods and lower risk of bias were more likely to report a neutral association of digoxin with mortality (P<0.001). Across all study types, digoxin led to a small but significant reduction in all cause hospital admission (risk ratio 0.92, 0.89 to 0.95; P<0.001; n=29,525). CONCLUSIONS Digoxin is associated with a neutral effect on mortality in randomised trials and a lower rate of admissions to hospital across all study types. Regardless of statistical analysis, prescription biases limit the value of observational data.
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Affiliation(s)
- Oliver J Ziff
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Royal Free London NHS Foundation Trust, London, UK
| | - Deirdre A Lane
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UK
| | - Monica Samra
- Royal Free London NHS Foundation Trust, London, UK
| | | | - Paulus Kirchhof
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UK
| | | | - Jonathan Townend
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Dipak Kotecha
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham, UK University Hospitals Birmingham NHS Trust, Birmingham, UK Monash Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
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13
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Hannah-Shmouni F, Seidelmann SB, Sirrs S, Mani A, Jacoby D. The Genetic Challenges and Opportunities in Advanced Heart Failure. Can J Cardiol 2015; 31:1338-50. [PMID: 26518444 DOI: 10.1016/j.cjca.2015.07.735] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 12/17/2022] Open
Abstract
The causes of heart failure are diverse. Inherited causes represent an important clinical entity and can be divided into 2 major categories: familial and metabolic cardiomyopathies. The distinct features that might be present in early disease states can become broadly overlapping with other diseases, such as in the case of inherited cardiomyopathies (ie, familial hypertrophic cardiomyopathy or mitochondrial diseases). In this review article, we focus on genetic issues related to advanced heart failure. Because of the emerging importance of this topic and its breadth, we sought to focus our discussion on the known genetic forms of heart failure syndromes, genetic testing, and newer data on pharmacogenetics and therapeutics in the treatment of heart failure, to primarily encourage clinicians to place a priority on the diagnosis and treatment of these potentially treatable conditions.
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Affiliation(s)
- Fady Hannah-Shmouni
- Advanced Heart Failure and Cardiomyopathy Program, Division of Cardiovascular Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Department of Internal Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Cardiovascular Genetics Program, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sara B Seidelmann
- Advanced Heart Failure and Cardiomyopathy Program, Division of Cardiovascular Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Department of Internal Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Cardiovascular Genetics Program, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sandra Sirrs
- Adult Metabolic Diseases Clinic, Division of Endocrinology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Arya Mani
- Department of Internal Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Cardiovascular Genetics Program, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Department of Genetics, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA
| | - Daniel Jacoby
- Advanced Heart Failure and Cardiomyopathy Program, Division of Cardiovascular Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA; Department of Internal Medicine, Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut, USA.
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14
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Fröhlich H, Zhao J, Täger T, Cebola R, Schellberg D, Katus HA, Grundtvig M, Hole T, Atar D, Agewall S, Frankenstein L. Carvedilol Compared With Metoprolol Succinate in the Treatment and Prognosis of Patients With Stable Chronic Heart Failure: Carvedilol or Metoprolol Evaluation Study. Circ Heart Fail 2015; 8:887-96. [PMID: 26175538 DOI: 10.1161/circheartfailure.114.001701] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 06/25/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND β-Blockers exert a prognostic benefit in the treatment of chronic heart failure. Their pharmacological properties vary. The only substantial comparative trial to date-the Carvedilol or Metoprolol European Trial-has compared carvedilol with short-acting metoprolol tartrate at different dose equivalents. We therefore addressed the relative efficacy of equal doses of carvedilol and metoprolol succinate on survival in multicenter hospital outpatients with chronic heart failure. METHODS AND RESULTS Four thousand sixteen patients with stable systolic chronic heart failure who were using either carvedilol or metoprolol succinate were identified in the Norwegian Heart Failure Registry and The Heart Failure Registry of the University of Heidelberg, Germany. Patients were individually matched on both the dose equivalents and the respective propensity scores for β-blocker treatment. During a follow-up for 17 672 patient-years, it was found that 304 (27.2%) patients died in the carvedilol group and 1066 (36.8%) in the metoprolol group. In a univariable analysis of the general sample, metoprolol therapy was associated with higher mortality compared with carvedilol therapy (hazard ratio, 1.49; 95% confidence interval, 1.31-1.69; P<0.001). This difference was not seen after multivariable adjustment (hazard ratio, 0.93; 95% confidence interval, 0.57-1.50; P=0.75) and adjustment for propensity score and dose equivalents (hazard ratio, 1.06; 95% confidence interval, 0.94-1.20; P=0.36) or in the propensity and dose equivalent-matched sample (hazard ratio, 1.00; 95% confidence interval, 0.82-1.23; P=0.99). These results were essentially unchanged for all prespecified subgroups. CONCLUSIONS In outpatients with chronic heart failure, no conclusive association between all-cause mortality and treatment with carvedilol or metoprolol succinate was observed after either multivariable adjustment or multilevel propensity score matching.
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Affiliation(s)
- Hanna Fröhlich
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Jingting Zhao
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Tobias Täger
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Rita Cebola
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Dieter Schellberg
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Hugo A Katus
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Morten Grundtvig
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Torstein Hole
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Dan Atar
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Stefan Agewall
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.)
| | - Lutz Frankenstein
- From the Department of Cardiology, University of Heidelberg, Heidelberg, Germany (H.F., J.Z., T.T., R.C., D.S., L.F.); Medical Department, Innlandet Hospital Trust Division Lillehammer, Lillehammer, Norway (M.G.); Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway (T.H.); Medical Clinic, Helse Møre and Romsdal HF, Ålesund, Norway (T.H.); and Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Oslo, Norway (D.A., S.A.).
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15
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Kotecha D, Altman DG, Manzano L, Flather MD. β blockers in patients with heart failure and atrial fibrillation - Authors' reply. Lancet 2015; 385:1618-9. [PMID: 25943812 DOI: 10.1016/s0140-6736(15)60789-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Dipak Kotecha
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia.
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
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16
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Kotecha D, Holmes J, Krum H, Altman DG, Manzano L, Cleland JGF, Lip GYH, Coats AJS, Andersson B, Kirchhof P, von Lueder TG, Wedel H, Rosano G, Shibata MC, Rigby A, Flather MD. Efficacy of β blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis. Lancet 2014; 384:2235-43. [PMID: 25193873 DOI: 10.1016/s0140-6736(14)61373-8] [Citation(s) in RCA: 405] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Atrial fibrillation and heart failure often coexist, causing substantial cardiovascular morbidity and mortality. β blockers are indicated in patients with symptomatic heart failure with reduced ejection fraction; however, the efficacy of these drugs in patients with concomitant atrial fibrillation is uncertain. We therefore meta-analysed individual-patient data to assess the efficacy of β blockers in patients with heart failure and sinus rhythm compared with atrial fibrillation. METHODS We extracted individual-patient data from ten randomised controlled trials of the comparison of β blockers versus placebo in heart failure. The presence of sinus rhythm or atrial fibrillation was ascertained from the baseline electrocardiograph. The primary outcome was all-cause mortality. Analysis was by intention to treat. Outcome data were meta-analysed with an adjusted Cox proportional hazards regression. The study is registered with Clinicaltrials.gov, number NCT0083244, and PROSPERO, number CRD42014010012. FINDINGS 18,254 patients were assessed, and of these 13,946 (76%) had sinus rhythm and 3066 (17%) had atrial fibrillation at baseline. Crude death rates over a mean follow-up of 1·5 years (SD 1·1) were 16% (2237 of 13,945) in patients with sinus rhythm and 21% (633 of 3064) in patients with atrial fibrillation. β-blocker therapy led to a significant reduction in all-cause mortality in patients with sinus rhythm (hazard ratio 0·73, 0·67-0·80; p<0·001), but not in patients with atrial fibrillation (0·97, 0·83-1·14; p=0·73), with a significant p value for interaction of baseline rhythm (p=0·002). The lack of efficacy for the primary outcome was noted in all subgroups of atrial fibrillation, including age, sex, left ventricular ejection fraction, New York Heart Association class, heart rate, and baseline medical therapy. INTERPRETATION Based on our findings, β blockers should not be used preferentially over other rate-control medications and not regarded as standard therapy to improve prognosis in patients with concomitant heart failure and atrial fibrillation. FUNDING Menarini Farmaceutica Internazionale (administrative support grant).
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Affiliation(s)
- Dipak Kotecha
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK; Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust, London, UK; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia.
| | - Jane Holmes
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK; Hull York Medical School, University of Hull, Kingston upon Hull, UK
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK; City Hospital, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Andrew J S Coats
- Monash University, Melbourne, VIC, Australia; Warwick University, Warwick, UK
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Paulus Kirchhof
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK; City Hospital, Sandwell and West Birmingham NHS Trust, Birmingham, UK; Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | - Thomas G von Lueder
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia; Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hans Wedel
- Nordic School of Public Health, Gothenburg, Sweden
| | - Giuseppe Rosano
- Department of Medical Sciences, Instituto di Ricovero e Cura a Carattere Scientifico San Raffaele Pisana, Rome, Italy
| | | | - Alan Rigby
- Academic Cardiology, Castle Hill Hospital, Kingston upon Hull, UK
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Kotecha D, Kirchhof P. Rate and rhythm control have comparable effects on mortality and stroke in atrial fibrillation but better data are needed. ACTA ACUST UNITED AC 2014; 19:222-3. [PMID: 25147301 DOI: 10.1136/ebmed-2014-110062] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Dipak Kotecha
- Centre for Cardiovascular Sciences, Medical School, University of Birmingham, Birmingham, UK Monash Centre of Cardiovascular Research & Education in Therapeutics, Monash University, Melbourne, Australia
| | - Paul Kirchhof
- Centre for Cardiovascular Sciences, Medical School, University of Birmingham, Birmingham, UK Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
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Pringle JL, Boyer A, Conklin MH, McCullough JW, Aldridge A. The Pennsylvania Project: Pharmacist Intervention Improved Medication Adherence And Reduced Health Care Costs. Health Aff (Millwood) 2014; 33:1444-52. [DOI: 10.1377/hlthaff.2013.1398] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Janice L. Pringle
- Janice L. Pringle ( ) is director of the Program Evaluation and Research Unit at the University of Pittsburgh School of Pharmacy, in Pennsylvania
| | - Annette Boyer
- Annette Boyer is vice president of business development at CECity Inc., in Homestead, Pennsylvania
| | - Mark H. Conklin
- Mark H. Conklin is vice president of operations at Pharmacy Quality Solutions, in Sewickley, Pennsylvania
| | - Jesse W. McCullough
- Jesse W. McCullough is director of field clinical services at Rite Aid Corp., in Pittsburgh
| | - Arnie Aldridge
- Arnie Aldridge is an economist at RTI International in Durham, North Carolina
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González-García A, Montero Pérez-Barquero M, Formiga F, González-Juanatey JR, Quesada MA, Epelde F, Oropesa R, Díez-Manglano J, Cerqueiro JM, Manzano L. Has beta-blocker use increased in patients with heart failure in internal medicine settings? Prognostic implications: RICA registry. ACTA ACUST UNITED AC 2014; 67:196-202. [PMID: 24774394 DOI: 10.1016/j.rec.2013.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 07/25/2013] [Indexed: 01/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES Underuse of beta-blockers has been reported in elderly patients with heart failure. The aim of this study was to evaluate the current prescription of beta-blockers in the internal medicine setting, and its association with morbidity and mortality in heart failure patients. METHODS The information analyzed was obtained from a prospective cohort of patients hospitalized for heart failure (RICA registry] database, patients included from March 2008 to September 2011) with at least one year of follow-up. We investigated the percentage of patients prescribed beta-blockers at hospital discharge, and at 3 and 12 months, and the relationship of beta-blocker use with mortality and readmissions for heart failure. Patients with significant valve disease were excluded. RESULTS A total of 515 patients were analyzed (53.5% women), with a mean age of 77.1 (8.7) years. Beta-blockers were prescribed in 62.1% of patients at discharge. A similar percentage was found at 3 months (65.6%) and 12 months (67.9%) after discharge. All-cause mortality and the composite of all-cause mortality and readmission for heart failure were significantly lower in patients treated with beta-blockers (hazard ratio=0.59, 95% confidence interval, 0.41-0.84 vs hazard ratio=0.64, 95% confidence interval, 0.49-0.83). This decrease in mortality was maintained after adjusting by age, sex, ejection fraction, functional class, comorbidities, and concomitant treatment. CONCLUSIONS The findings of this study indicate that beta-blocker use is increasing in heart failure patients (mainly elderly) treated in the internal medicine setting, and suggest that the use of these drugs is associated with a reduction in clinical events.
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Affiliation(s)
- Andrés González-García
- Unidad de Insuficiencia Cardiaca y Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | | | - Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José R González-Juanatey
- Servicio Cardiología y UCC, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | | | - Francisco Epelde
- Unidad de Soporte a Urgencias, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Roberto Oropesa
- Servicio de Medicina Interna, Hospital Can Misses, Ibiza, Balearic Islands, Spain
| | | | - José M Cerqueiro
- Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - Luis Manzano
- Unidad de Insuficiencia Cardiaca y Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain.
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González-García A, Montero Pérez-Barquero M, Formiga F, González-Juanatey JR, Quesada MA, Epelde F, Oropesa R, Díez-Manglano J, Cerqueiro JM, Manzano L. ¿Se ha incrementado el uso de bloqueadores beta en pacientes con insuficiencia cardiaca en medicina interna? Implicaciones pronósticas: registro RICA. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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