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Galos G, Szabados E, Rabai M, Szalai R, Ferkai LA, Papp I, Toth K, Sandor B. Evaluation of Incidence and Risk Factors of Sudden Cardiac Death in Patients with Chronic Coronary Syndrome Attending Physical Training. Cardiol Ther 2023; 12:689-701. [PMID: 37803155 DOI: 10.1007/s40119-023-00331-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/04/2023] [Indexed: 10/08/2023] Open
Abstract
INTRODUCTION Regular physical activity is recommended to patients with chronic coronary syndrome (CCS). However, vigorous physical exercise occurs as a risk factor of sudden cardiac death (SCD). The effect of short-term and irregular exercise is controversial. The aim of this research is to assess the role of regular training in the incidence of SCD and to identify risk factors among patients with CCS participating in a long-term training program. METHODS Data of risk factors, therapy, and participation were collected retrospectively for a 10-year period, assessing the length and regularity of participation. The incidence of SCD and related mortality was registered. ANOVA, χ2 test, and multinominal logistic regression and stepwise analysis were performed. RESULTS The Incidence of chronic kidney disease (CKD) was higher (p < 0.01) and taking beta-blockers (BBs) was lower (p = 0.04) in the SCD group. Irregular training, lack of BBs, smoking, and CKD increased the risk of SCD, while female sex, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers (ACEI/ARBs), and BBs decreased the risk of SCD. CONCLUSIONS Taking ACEI/ARBs and BBs proved to be a protective factor, emphasizing the use of optimal medical therapy. Assessment of cardiac risk factors and control of comorbidities also proved to be important. The occurrence of SCD was connected to irregular physical activity, probably relating to the adverse effects of ad hoc exercising.
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Affiliation(s)
- Gergely Galos
- Division of Cardiology, 1st Department of Medicine, Medical School, University of Pecs, 7624, Pecs, Hungary
- Division of Preventive Cardiology and Rehabilitation, 1st Department of Medicine, Medical School, University of Pecs, 13 Ifjusag Str., Pecs, 7624, Hungary
| | - Eszter Szabados
- Division of Preventive Cardiology and Rehabilitation, 1st Department of Medicine, Medical School, University of Pecs, 13 Ifjusag Str., Pecs, 7624, Hungary
| | - Miklos Rabai
- Division of Cardiology, 1st Department of Medicine, Medical School, University of Pecs, 7624, Pecs, Hungary
| | - Rita Szalai
- Division of Cardiology, 1st Department of Medicine, Medical School, University of Pecs, 7624, Pecs, Hungary
- Division of Preventive Cardiology and Rehabilitation, 1st Department of Medicine, Medical School, University of Pecs, 13 Ifjusag Str., Pecs, 7624, Hungary
| | - Luca Anna Ferkai
- Doctoral School of Health Sciences, University of Pecs, 7621, Pecs, Hungary
| | - Ildiko Papp
- Division of Preventive Cardiology and Rehabilitation, 1st Department of Medicine, Medical School, University of Pecs, 13 Ifjusag Str., Pecs, 7624, Hungary
| | - Kalman Toth
- Division of Cardiology, 1st Department of Medicine, Medical School, University of Pecs, 7624, Pecs, Hungary
| | - Barbara Sandor
- Division of Preventive Cardiology and Rehabilitation, 1st Department of Medicine, Medical School, University of Pecs, 13 Ifjusag Str., Pecs, 7624, Hungary.
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Davis LE, Pogge EK, Garg R. Are beta-blockers safe and effective after myocardial infarction in patients with COPD? JAAPA 2023; 36:13-15. [PMID: 36815843 DOI: 10.1097/01.jaa.0000918804.17000.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
ABSTRACT Clinicians may be hesitant to prescribe beta-blockers in patients with chronic obstructive pulmonary disease (COPD) who have a comorbid compelling cardiovascular indication for beta-blocker therapy. This article summarizes the available data on the safety and efficacy of beta-blockers in patients with COPD and recent myocardial infarction.
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Affiliation(s)
- Lindsay E Davis
- At the time this article was written, Lindsay E. Davis was a professor at Midwestern University College of Pharmacy in Glendale, Ariz. She is now a cardiology director in the internal medicine field medical group at Pfizer in Peoria, Ariz., and an adjunct professor at Midwestern University. Elizabeth K. Pogge is a professor at Midwestern University College of Pharmacy. Rajeev Garg is an interventional cardiologist at Heart One Associates in Phoenix, Ariz. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Suc G, Zeitouni M, Procopi N, Guedeney P, Kerneis M, Barthelemy O, Le Feuvre C, Helft G, Rouanet S, Brugier D, Collet JP, Vicaut E, Montalescot G, Silvain J. Beta-blocker prescription and outcomes in uncomplicated acute myocardial infarction: Insight from the ePARIS registry. Arch Cardiovasc Dis 2023; 116:25-32. [PMID: 36549972 DOI: 10.1016/j.acvd.2022.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/16/2022] [Accepted: 10/25/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Systematic prescription of beta-blockers after myocardial infarction remains an open question in the era of revascularization, especially for patients with uncomplicated myocardial infarction. OBJECTIVE To evaluate in a real-life registry the proportion of patients with uncomplicated myocardial infarction (preserved left ventricular ejection fraction and no cardiovascular event within the first 6 months), and to report their characteristics, outcomes and beta-blocker use. METHODS We included 1887 consecutive patients with ST-segment elevation myocardial infarction from the prospective ePARIS registry. Patients were divided into three groups: the "uncomplicated myocardial infarction" group (n=1060), defined by a left ventricular ejection fraction ≥ 40% and a 6-month period free from cardiovascular events; the "complicated myocardial infarction" group (n=366), defined by a left ventricular ejection fraction ≥ 40% and a recurrent cardiovascular event in the first 6 months; and the "left ventricular dysfunction" group (n=461), defined by a left ventricular ejection fraction<40%. RESULTS During a median follow-up of 2.7 years (interquartile range 1.0-4.9 years), the "uncomplicated myocardial infarction" group was at low mortality risk compared with the "complicated myocardial infarction" group (hazard ratio 0.38, 95% confidence interval 0.25-0.58; P<0.01) and the "left ventricular dysfunction" group (hazard ratio 0.22, 95% confidence interval 0.15-0.32; P<0.01). Beta-blockers were prescribed at discharge predominantly in the "uncomplicated myocardial infarction" group (93%) compared with 87% in the "complicated myocardial infarction" group and 81% in the "left ventricular dysfunction" group. CONCLUSIONS Beta-blockers are less prescribed in patients who may need them the most. The benefit of beta-blockers-largely prescribed in lower-risk patients-remains to be shown beyond the first 6 months for these patients with no left ventricular dysfunction and no recurrent events.
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Affiliation(s)
- Gaspard Suc
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Michel Zeitouni
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Niki Procopi
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Mathieu Kerneis
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Olivier Barthelemy
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Claude Le Feuvre
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Gérard Helft
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Stéphanie Rouanet
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France; StatEthic, 92300 Levallois-Perret, France
| | - Delphine Brugier
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Eric Vicaut
- Unité de recherche clinique, ACTION Study Group, Hôpital Fernand-Widal, AP-HP, 75010 Paris, France; Statistique, Analyse et Modélisation Multidisciplinaire (SAMM), EA 4543, Université Paris 1 Panthéon Sorbonne, 75013 Paris, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Inserm UMRS 1166, Hôpital Pitié-Salpêtrière, AP-HP, 75013 Paris, France.
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Ojji D, Ale BM, Shedul L, Umuerri E, Ejim E, Alikor C, Agunyenwa C, Njideofor U, Eze H, Ansa V. The Effect of Nebivolol on Office Blood Pressure of Blacks Residing in Sub-Saharan Africa (A Pilot Study). Front Cardiovasc Med 2021; 7:613917. [PMID: 33505995 PMCID: PMC7829216 DOI: 10.3389/fcvm.2020.613917] [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] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: There is substantial clinical evidence that monotherapy with beta-blockers are less effective in reducing blood pressure among hypertensive Black patients compared to Whites. The highly selective beta-1 agents like nebivolol and bisoprolol have, however, been reported to be effective in reducing blood pressure in African Americans. However, results in African Americans cannot be extrapolated to native Africans because of genetic admixture and gene-environment interaction. There is, therefore, the need for us to generate data that are applicable to Africans residing in sub-Saharan Africa. We therefore decided to evaluate the efficacy and tolerability of highly selective beta-1 agent nebivolol in hypertensive Black patients residing in sub-Saharan Africa. Materials and Methods: The nebivolol study was a multicenter, prospective, observational program among hypertensive patients with 4- and 8-week follow up which was conducted in 5 cities in Nigeria of Abuja, Calabar, Enugu, Oghara, and Port Harcourt. Dosages of nebivolol used in keeping with local prescribing information were 5 and 10 mg once daily each. The effectiveness of treatment was assessed by change from baseline in mean office systolic and diastolic blood pressures, and the proportion of patients achieving the therapeutic goal of <140/90 mmHg. Safety and tolerability of this medication were also assessed. Results: We report the results of the 140 patients studied. The mean age and body mass index were 46.9 ± 7.3 years and 22.3 ± 5.8 kg/m2, respectively, and 57.1% were female. Nebivolol reduced SBP and DBP by 7.6 and 6.6 mmHg, respectively, in 4 weeks, and by 11.1 and 8.0 mm Hg, respectively, in 8 weeks. Blood pressure control was achieved in 54.8% of the patients in 4 weeks and increased to 60.4% in 8 weeks. There was no change in metabolic profile between randomization and at 8 weeks, and erectile dysfunction occurred in 1.3% of the study population. Conclusions: Nebivolol 5 and 10 mg appear efficacious in Nigerian Africans with no negative metabolic effect and minimal side effect profile. Clinical Trial Registration: www.ClinicalTrials.gov, Study Identification: NCT03598673.
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Affiliation(s)
- Dike Ojji
- Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Nigeria.,Cardiovacular Research Unit, Department of Internal Medicine, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Nigeria
| | | | - Lamkur Shedul
- Department of Family Medicine, University of Abuja Teaching Hospital, Gwagwalada, Nigeria
| | - Ejiroghene Umuerri
- Department of Internal Medicine, Faculty of Clinical Medicine, College of Health Sciences, Delta State University, Abraka, Nigeria.,Delta State University Teaching Hospital, Oghara, Nigeria
| | - Emmanuel Ejim
- Department of Internal Medicine, University of Nigeria and University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chizindu Alikor
- Department of Internal Medicine, University of Port Harcourt and University of Port Harcourt Teaching, Port Harcourt, Nigeria
| | - Charles Agunyenwa
- Department of Internal Medicine, University of Nigeria and University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Uche Njideofor
- Department of Internal Medicine, University of Calabar and University of Calabar Teaching Hospital, Calabar, Nigeria
| | - Helen Eze
- Cardiovacular Research Unit, Department of Internal Medicine, University of Abuja and University of Abuja Teaching Hospital, Gwagwalada, Nigeria
| | - Victor Ansa
- Department of Internal Medicine, University of Calabar and University of Calabar Teaching Hospital, Calabar, Nigeria
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Ji S, Guo R, Wang J, Qian L, Liu M, Xu H, Zhang J, Guan Y, Yang G, Chen L. Microsomal Prostaglandin E 2 Synthase-1 Deletion Attenuates Isoproterenol-Induced Myocardial Fibrosis in Mice. J Pharmacol Exp Ther 2020; 375:40-48. [PMID: 32759273 DOI: 10.1124/jpet.120.000023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/10/2020] [Indexed: 11/22/2022] Open
Abstract
Deletion of microsomal prostaglandin E2 synthase-1 (mPGES-1) inhibits inflammation and protects against atherosclerotic vascular diseases but displayed variable influence on pathologic cardiac remodeling. Overactivation of β-adrenergic receptors (β-ARs) causes heart dysfunction and cardiac remodeling, whereas the role of mPGES-1 in β-AR-induced cardiac remodeling is unknown. Here we addressed this question using mPGES-1 knockout mice, subjecting them to isoproterenol, a synthetic nonselective agonist for β-ARs, at 5 or 15 mg/kg per day to induce different degrees of cardiac remodeling in vivo. Cardiac structure and function were assessed by echocardiography 24 hours after the last of seven consecutive daily injections of isoproterenol, and cardiac fibrosis was examined by Masson trichrome stain in morphology and by real-time polymerase chain reaction for the expression of fibrosis-related genes. The results showed that deletion of mPGES-1 had no significant effect on isoproterenol-induced cardiac dysfunction or hypertrophy. However, the cardiac fibrosis was dramatically attenuated in the mPGES-1 knockout mice after either low-dose or high-dose isoproterenol exposure. Furthermore, in vitro study revealed that overexpression of mPGES-1 in cultured cardiac fibroblasts increased isoproterenol-induced fibrosis, whereas knocking down mPGES-1 in cardiac myocytes decreased the fibrogenesis of fibroblasts. In conclusion, mPGES-1 deletion protects against isoproterenol-induced cardiac fibrosis in mice, and targeting mPGES-1 may represent a novel strategy to attenuate pathologic cardiac fibrosis, induced by β-AR agonists. SIGNIFICANCE STATEMENT: Inhibitors of microsomal prostaglandin E2 synthase-1 (mPGES-1) are being developed as alternative analgesics that are less likely to elicit cardiovascular hazards than cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs. We have demonstrated that deletion of mPGES-1 protects inflammatory vascular diseases and promotes post-myocardial infarction survival. The role of mPGES-1 in β-adrenergic receptor-induced cardiomyopathy is unknown. Here we illustrated that deletion of mPGES-1 alleviated isoproterenol-induced cardiac fibrosis without deteriorating cardiac dysfunction. These results illustrated that targeting mPGES-1 may represent an efficacious approach to the treatment of inflammatory cardiovascular diseases.
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Affiliation(s)
- Shuang Ji
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Rui Guo
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Jing Wang
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Lei Qian
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Min Liu
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Hu Xu
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Jiayang Zhang
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Youfei Guan
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Guangrui Yang
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
| | - Lihong Chen
- Advanced Institute for Medical Sciences, Dalian Medical University, China (S.J., R.G., J.W., L.Q., M.L., H.X., J.Z., Y.G., L.C.) and School of Bioengineering, Dalian University of Technology, China (G.Y.)
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Dungan K, Merrill J, Long C, Binkley P. Effect of beta blocker use and type on hypoglycemia risk among hospitalized insulin requiring patients. Cardiovasc Diabetol 2019; 18:163. [PMID: 31775749 PMCID: PMC6882013 DOI: 10.1186/s12933-019-0967-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/10/2019] [Indexed: 01/30/2023] Open
Abstract
Background Although beta blockers could increase the risk of hypoglycemia, the difference between subtypes on hypoglycemia and mortality have not been studied. This study sought to determine the relationship between type of beta blocker and incidence of hypoglycemia and mortality in hospitalized patients. Methods We retrospectively identified non-critically ill hospitalized insulin requiring patients who were undergoing bedside glucose monitoring and received either carvedilol or a selective beta blocker (metoprolol or atenolol). Patients receiving other beta blockers were excluded. Hypoglycemia was defined as any glucose < 3.9 mmol/L within 24 h of admission (Hypo1day) or throughout hospitalization (HypoT) and any glucose < 2.2 mmol/L throughout hospitalization (Hyposevere). Results There were 1020 patients on carvedilol, 886 on selective beta blockers, and 10,216 on no beta blocker at admission. After controlling for other variables, the odds of Hypo1day, HypoT and Hyposevere were higher for carvedilol and selective beta blocker recipients than non-recipients, but only in basal insulin nonusers. The odds of Hypo1day (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.28, 3.09, p = 0.0002) and HypoT (OR 1.38, 95% CI 1.02, 1.86, p = 0.03) but not Hyposevere (OR 1.90, 95% CI 0.90, 4.02, p = 0.09) were greater for selective beta blocker vs. carvedilol recipients in basal insulin nonusers. Hypo1day, HypoT, and Hyposevere were all associated with increased mortality in adjusted models among non-beta blocker and selective beta blocker recipients, but not among carvedilol recipients. Conclusions Beta blocker use is associated with increased odds of hypoglycemia among hospitalized patients not requiring basal insulin, and odds are greater for selective beta blockers than for carvedilol. The odds of hypoglycemia-associated mortality are increased with selective beta blocker use or nonusers but not in carvedilol users, warranting further study.
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Affiliation(s)
- Kathleen Dungan
- Division of Endocrinology, Diabetes & Metabolism, The Ohio State University, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH, 43210-1296, USA.
| | - Jennifer Merrill
- Division of Endocrinology, Duke University, 30 Duke Medicine Circle, Durham, NC, 22710, USA
| | - Clarine Long
- The Ohio State University College of Medicine, 370 W. 9th Ave, Columbus, OH, 43210, USA
| | - Philip Binkley
- Division of Cardiovascular Medicine, The Ohio State University, 452 W. 10th Ave, Columbus, OH, 43210, USA
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Ivanova I, Elseviers M, Wettermark B, Schmidt Mende K, Vander Stichele R, Christiaens T. Electronic assessment of cardiovascular potentially inappropriate medications in an administrative population database. Basic Clin Pharmacol Toxicol 2018; 124:62-73. [DOI: 10.1111/bcpt.13095] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/08/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Ivana Ivanova
- Clinical Pharmacology Research Unit; Heymans Institute of Pharmacology; Ghent University; Ghent Belgium
| | - Monique Elseviers
- Clinical Pharmacology Research Unit; Heymans Institute of Pharmacology; Ghent University; Ghent Belgium
- Centre For Research and Innovation in Care (CRIC); University of Antwerp; Wilrijk Belgium
| | - Bjorn Wettermark
- Public Healthcare Services Committee Administration; Stockholm County Council; Stockholm Sweden
- Department of Medicine; Unit for Clinical Epidemiology; Centre for Pharmacoepidemiology; Karolinska Institutet; Stockholm Sweden
| | - Katharina Schmidt Mende
- Academic Primary Health Care Center; Stockholm County Council; Huddinge Sweden
- Department of Neurobiology, Care Sciences and Society; Division of Family Medicine; Karolinska Institute; Huddinge Sweden
| | - Robert Vander Stichele
- Clinical Pharmacology Research Unit; Heymans Institute of Pharmacology; Ghent University; Ghent Belgium
| | - Thierry Christiaens
- Clinical Pharmacology Research Unit; Heymans Institute of Pharmacology; Ghent University; Ghent Belgium
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β-blocker dosage and outcomes after acute coronary syndrome. Am Heart J 2017; 184:26-36. [PMID: 27892884 DOI: 10.1016/j.ahj.2016.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 10/17/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although β-blockers increase survival in acute coronary syndrome (ACS) patients, the doses used in trials were higher than doses used in practice, and recent data do not support an advantage of higher doses. We hypothesized that rates of major adverse cardiac events (MACE), all-cause death, myocardial infarction, and stroke are equivalent for patients on low-dose and high-dose β-blocker. METHODS Patients admitted to Intermountain Healthcare with ACS and diagnosed with ≥70% coronary stenosis between 1994 and 2013 were studied (N = 7,834). We classified low dose as ≤25% and high dose as ≥50% of an equivalent daily dose of 200 mg of metoprolol. Multivariate analyses were used to test association between low-dose versus high-dose β-blocker dosage and MACE at 0-6 months and 6-24 months. RESULTS A total of 5,287 ACS subjects were discharged on β-blockers (87% low dose, 12% high dose, and 1% intermediate dose). The 6-month MACE outcomes rates for the β-blocker dosage (low versus high) were not equivalent (P = .18) (hazard ratio [HR] = 0.76; 95% CI, 0.52-1.10). However, subjects on low-dose β-blocker therapy did have a significantly decreased risk of myocardial infarction for 0-6 months (HR = 0.53; 95% CI, 0.33-0.86). The rates of MACE events during the 6-24 months after presentation with ACS were equivalent for the 2 doses (P = .009; HR = 1.03 [95% CI, 0.70-1.50]). CONCLUSIONS In ACS patients, rates of MACE for high-dose and low-dose β-blocker doses are similar. These findings question the importance of achieving a high dose of β-blocker in ACS patients and highlight the need for further investigation of this clinical question.
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Hickson RP, Brancato CJ, Moga DC. Predictors of β-Blocker Initiation After Myocardial Infarction in Patients With Type 2 Diabetes. J Pharm Technol 2016. [DOI: 10.1177/8755122516649204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Beta-blockers remain important for secondary prevention after myocardial infarction (MI). Despite clinical guideline recommendations, underutilization of this pharmacotherapy continues in patients with type 2 diabetes (T2DM) compared to the general post-MI population. Objective: This study aimed to (1) quantify the proportion of T2DM patients utilizing β-blocker therapy within 30 days of hospital discharge after MI and (2) identify clinical and demographic characteristics predicting initiation of β-blocker therapy. Methods: A retrospective cohort of US employed, commercially insured individuals was assembled using de-identified enrollment files, medical claims, and pharmacy claims from 2007 to 2009. Inclusion criteria were the following: (1) type 2 diabetes, (2) ≥18 years old, (3) continuous eligibility, (4) MI. Multivariable logistic regression with adjusted odds ratios (ORadj) using manual backward elimination was used to identify predictors of β-blocker initiation within 30 days of discharge from index hospitalization. Results: Of 341 T2DM patients, 167 (49.0%) were new users and 174 (51.0%) were nonusers of β-blockers within 30 days of post-MI hospital discharge. Patients on a calcium channel blocker (ORadj 2.63) and patients taking 1 to 5 medications (ORadj 3.59) were more likely to initiate β-blockers post-MI. Patients with heart failure (ORadj 0.45) or an arrhythmia (ORadj 0.44) were less likely to initiate β-blockers as well as patients with renal failure not taking a diuretic (ORadj 0.17). Conclusions: These results confirm previous findings that β-blockers are underutilized in T2DM patients post-MI. Predictors from the regression model can guide future research investigating how this deviation from guidelines is attributed to prescriber versus patient behavior.
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Initiation of β-blocker therapy and depression after acute myocardial infarction. Am Heart J 2016; 174:37-42. [PMID: 26995368 DOI: 10.1016/j.ahj.2015.11.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 11/19/2015] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Although β-blockers reduce mortality after acute myocardial infarction (AMI), early reports linking β-blocker use with subsequent depression have potentially limited their use in vulnerable patients. We sought to provide empirical evidence to support or refute this concern by examining the association between β-blocker initiation and change in depressive symptoms in AMI patients. METHODS Using data from 2 US multicenter, prospective registries of AMI patients, we examined 1-, 6-, and 12-month changes in depressive symptoms after the index hospitalization among patients who were β-blocker-naïve on admission. Depressive symptoms were assessed using the validated 8-item Patient Health Questionnaire (PHQ-8), which rates depressive symptoms from 0 to 24, with higher scores indicating more depressive symptoms. A propensity-matched repeated-measures linear regression model was used to compare change in depressive symptoms among patients who were and were not initiated on a β-blocker after AMI. RESULTS Of 3,470 AMI patients who were β-blocker-naïve on admission, 3,190 (91.9%) were initiated on a β-blocker and 280 (8.1%) were not. Baseline PHQ-8 scores were higher in patients not initiated on a β-blocker (mean 5.78 ± 5.45 vs 4.88 ± 5.11, P = .005). PHQ-8 scores were progressively lower at 1, 6, and 12 months in both the β-blocker (mean decrease at 12 months 1.16, P < .0001) and no-β-blocker groups (mean decrease 1.71, P < .0001). After propensity matching 201 untreated patients with 567 treated patients, initiation of β-blocker therapy was not associated with a difference in mean change in PHQ-8 scores at 1, 6, or 12 months after AMI (absolute mean difference with β-blocker initiation at 12 months of 0.08, 95% CI -0.81 to 0.96, P = .86). CONCLUSIONS Initiation of β-blocker therapy after AMI was not associated with an increase in depressive symptoms. Restricting β-blocker use because of concerns about depression appears unwarranted and may lead to undertreatment of AMI patients.
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Arthroscopy for Knee Osteoarthritis Has Not Decreased After a Clinical Trial. Clin Orthop Relat Res 2016; 474:489-94. [PMID: 26290345 PMCID: PMC4709284 DOI: 10.1007/s11999-015-4514-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple clinical trials have shown that arthroscopy for knee osteoarthritis is not efficacious. It is unclear how these studies have affected orthopaedic practice in the USA. QUESTIONS/PURPOSES We questioned whether, in the Veterans Health Administration system, rates of knee arthroscopy in patients with osteoarthritis have changed after publication of the initial clinical trial by Moseley et al. in 2002, and whether rates of arthroplasty within 2 years of arthroscopy have changed during the same period. METHODS Patients 50 years and older with knee osteoarthritis who underwent arthroscopy between 1998 and 2010 were retrospectively identified and an annual arthroscopy rate was calculated from 1998 through 2002 and from 2006 through 2010. Patients who underwent knee arthroplasty within 2 years of arthroscopy during each period were identified, and a 2-year conversion to arthroplasty rate was calculated. RESULTS Between 1998 and 2002, the annual arthroscopy rate decreased from 4% to 3%. Of these arthroscopies, 4% were converted to arthroplasty within 2 years. Between 2006 and 2010, the annual arthroscopy rate increased from 3% to 4%. Of these arthroscopies, 5% were converted to arthroplasty within 2 years. CONCLUSIONS Rates of arthroscopy in patients with knee osteoarthritis and conversion to arthroplasty within 2 years have not decreased with time. It may be that evidence alone is not sufficient to alter practice patterns or that arthroscopy rates for arthritis for patients in the Veterans Health Administration system were already so low that the results of the initial clinical trial had no substantial effect. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Poirier L, Tobe SW. Contemporary Use of β-Blockers: Clinical Relevance of Subclassification. Can J Cardiol 2014; 30:S9-S15. [DOI: 10.1016/j.cjca.2013.12.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/29/2013] [Accepted: 12/01/2013] [Indexed: 12/19/2022] Open
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Radchenko GD, Sirenko YM, Kushnir SM, Torbas OO, Dobrokhod AS. Comparative effectiveness of a fixed-dose combination of losartan + HCTZ versus bisoprolol + HCTZ in patients with moderate-to-severe hypertension: results of the 6-month ELIZA trial. Vasc Health Risk Manag 2013; 9:535-49. [PMID: 24109189 PMCID: PMC3792946 DOI: 10.2147/vhrm.s44568] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The aim of this study was to compare the antihypertensive efficacy of losartan 100 mg + hydrochlorothiazide (HCTZ) 25 mg versus bisoprolol 10 mg + HCTZ 25 mg and their influence on arterial stiffness and central blood pressure (BP). Methods Of 60 patients with a mean BP of 173.3 ± 1.7/98.4 ± 1.2 mmHg, 59 were random-ized to losartan + HCTZ (n = 32) or bisoprolol + HCTZ (n = 27). Amlodipine was added if target BP was not achieved at 1 month, and doxazosin was added if target BP was not achieved after 3 months. Body mass index, office and 24-hour ambulatory BP, pulse wave velocity (carotid-femoral [PWVE] and radial [PWVM]), noninvasive central systolic BP, augmentation index (AIx), laboratory investigations, and electrocardiography were done at baseline and after 6 months of treatment. Results Losartan + HCTZ was as effective as bisoprolol + HCTZ, with target office BP achieved in 96.9% and 92.6% of patients and target 24-hour BP in 75% and 66.7% of patients, respectively, after 6 months. Effective treatment of BP led to significant lowering of central systolic BP, but this was decreased to a significantly (P < 0.05) greater extent by losartan + HCTZ (−23.0 ± 2.3 mmHg) than by bisoprolol + HCTZ (−15.4 ± 2.9 mmHg) despite equal lowering of brachial BP. Factors correlated with central systolic BP and its lowering differed between the treatment groups. Losartan + HCTZ did not alter arterial stiffness patterns significantly, but bisoprolol + HCTZ significantly increased AIx. We noted differences in ΔPWVE, ΔPWVM, and ΔAIx between the groups in favor of losartan + HCTZ. Decreased heart rate was associated with higher central systolic BP and AIx in the bisoprolol + HCTZ group, but was not associated with increased AIx in the losartan + HCTZ group. Conclusion Although both treatments decreased both office and 24-hour BP, losartan + HCTZ significantly decreased central systolic BP and had a more positive influence on pulse wave velocity, with a less negative effect of decreased heart rate on AIx and central systolic BP.
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Affiliation(s)
- G D Radchenko
- Secondary Hypertension Department, National Scientific Center, Strazhesko Institute of Cardiology, Kiev, Ukraine
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Jones TE, Southcott A, Homan S. Drugs potentially affecting the extent of airways reversibility on pulmonary function testing are frequently consumed despite guidelines. Int J Chron Obstruct Pulmon Dis 2013; 8:383-8. [PMID: 23966777 PMCID: PMC3745286 DOI: 10.2147/copd.s44612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The increase in forced expiratory volume in one second (FEV1) effected by a bronchodilator is routinely assessed when patients undertake pulmonary function testing (PFT). Several drug classes can theoretically affect the magnitude of the increase in FEV1. Withholding periods are advised for many but not all such drugs. Anecdotally, many subjects presenting for PFT are found to have taken drugs that might affect the test. We did an audit of patients presenting for PFT to assess the frequency with which FEV1 reversibility might be affected by drugs. Methods One hundred subjects presenting to the laboratory for PFT were questioned about recent drug consumption by an independent pharmacy intern. Reversibility of FEV1 was assumed to have been affected if drugs of interest were consumed within defined withholding periods or two half-lives for drugs without such data. Results Sixty-three subjects were prescribed drugs likely to affect FEV1 reversibility. Thirty-six subjects consumed at least one such drug within the withholding period. Half (18) of these patients consumed β-blockers with or without β-agonists. Sixty-five subjects did not recall receiving any advice about withholding drugs prior to the test and only 10 recalled receiving advice from their clinician or pulmonary function technician. Conclusion Subjects presenting for PFT are infrequently advised to withhold drugs that may affect FEV1 reversibility, and consequently, often take such drugs close to the time of the test. Therefore, it is likely that the increase in FEV1 is frequently affected by interference from drugs and this might impact on diagnosis and/or treatment options.
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Affiliation(s)
- Terry E Jones
- Pharmacy Department, The Queen Elizabeth Hospital, Woodville South, SA, Australia.
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Jones TE, Ruffin RE, Arstall M. Cardiologists are more willing to prescribe β-blockers than respiratory physicians: an Australasian clinical scenario survey. Intern Med J 2013; 43:507-12. [DOI: 10.1111/imj.12035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 11/07/2012] [Indexed: 11/28/2022]
Affiliation(s)
- T. E. Jones
- Pharmacy Department; The Queen Elizabeth Hospital; Adelaide South Australia Australia
| | - R. E. Ruffin
- Department of Medicine; University of Adelaide; Adelaide South Australia Australia
| | - M. Arstall
- Cardiology Department; Lyell McEwin Health Service; Adelaide South Australia Australia
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Kärner A, Nilsson S, Jaarsma T, Andersson A, Wiréhn AB, Wodlin P, Hjelmfors L, Tingström P. The effect of problem-based learning in patient education after an event of CORONARY heart disease--a randomised study in PRIMARY health care: design and methodology of the COR-PRIM study. BMC FAMILY PRACTICE 2012; 13:110. [PMID: 23164044 PMCID: PMC3528480 DOI: 10.1186/1471-2296-13-110] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 11/15/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Even though there is convincing evidence that self-care, such as regular exercise and/or stopping smoking, alters the outcomes after an event of coronary heart disease (CHD), risk factors remain. Outcomes can improve if core components of secondary prevention programmes are structurally and pedagogically applied using adult learning principles e.g. problem-based learning (PBL). Until now, most education programs for patients with CHD have not been based on such principles. The basic aim is to discover whether PBL provided in primary health care (PHC) has long-term effects on empowerment and self-care after an event of CHD. METHODS/DESIGN A randomised controlled study is planned for patients with CHD. The primary outcome is empowerment to reach self-care goals. Data collection will be performed at baseline at hospital and after one, three and five years in PHC using quantitative and qualitative methodologies involving questionnaires, medical assessments, interviews, diaries and observations. Randomisation of 165 patients will take place when they are stable in their cardiac condition and have optimised cardiac medication that has not substantially changed during the last month. All patients will receive conventional care from their general practitioner and other care providers. The intervention consists of a patient education program in PHC by trained district nurses (tutors) who will apply PBL to groups of 6-9 patients meeting on 13 occasions for two hours over one year. Patients in the control group will not attend a PBL group but will receive home-sent patient information on 11 occasions during the year. DISCUSSION We expect that the 1-year PBL-patient education will improve patients' beliefs, self-efficacy and empowerment to achieve self-care goals significantly more than one year of standardised home-sent patient information. The assumption is that PBL will reduce cardiovascular events in the long-term and will also be cost-effective compared to controls. Further, the knowledge obtained from this study may contribute to improving patients' ability to handle self-care, and furthermore, may reduce the number of patients having subsequent CHD events in Sweden. TRIAL REGISTRATION NCT01462799.
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Affiliation(s)
- Anita Kärner
- Department of Social and Welfare studies (HAV), Linköping University, Linköping, Sweden
| | - Staffan Nilsson
- Vikbolandet Health Care Center, Primary Health Care in eastern Östergötland, County Council of Östergötland, Norrköping, Sweden
| | - Tiny Jaarsma
- Department of Social and Welfare studies (HAV), Linköping University, Linköping, Sweden
| | - Agneta Andersson
- Local Health Care Research and Development Unit, County Council in Östergötland, Linköping University, Linköping, Sweden
| | - Ann-Britt Wiréhn
- Local Health Care Research and Development Unit, County Council in Östergötland, Linköping University, Linköping, Sweden
| | - Peter Wodlin
- Department of Cardiology, County Council of Östergötland, Linköping University Hospital, Linköping, Sweden
| | - Lisa Hjelmfors
- Faculty of Health Sciences, Linkoping University, Linköping, Sweden
| | - Pia Tingström
- Department of Medical and Health Sciences (IMH), Linkoping University, Linköping, Sweden
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Recommendations for Managing Patients With Diabetes Mellitus in Cardiopulmonary Rehabilitation. J Cardiopulm Rehabil Prev 2012; 32:101-12. [DOI: 10.1097/hcr.0b013e31823be0bc] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
INTRODUCTION According to the convincing evidence, a decline in mortality rate has been achieved with beta-blockers in patients with an acute myocardial infarction and in post-infarction follow-up. In fact, there has been a clear reduction of sudden coronary death. The necessary condition for the efficiency of beta-blockers is an early use. They are also a medication of choice for angina after an infarction. The objective of this work was to evaluate the use of beta-blockers after a myocardial infarction in various clinical states and to eliminate doubts concerning their prescription. BETA BLOCKERS Even in conditions considered contraindications for administration of beta blockers such as old age, diabetes, non-Q-wave myocardial infarction, peripheral vascular disease, arterial disease, heart insufficiency; ventricular arrhythmias, renal disease, chronic obstructive pulmonary disease, asthma and depression, patients benefit from beta blockers when they are given along with a right choice of the medication and a regular followup of the patient. Preference is given to cardioselective beta blockers in patients with diabetes or lung disease. Beta-blockers do not cause long-term lipid alterations. Therefore, the matter of clinically significant alterations of lipids or blood glucose levels should not need further consideration as a problem of the treatment of diabetics. DISCUSSION AND CONCLUSION Investigations have proved that the use of beta-blockers reduces the development of cerebrovascular accidents, heart insufficiency and hypertension. Despite strong arguments and numerous recommendations, beta-blockers have not been accepted to a sufficient extent as an integral part of treatment of acute coronary syndrome and related diseases, to the detriment of many lost lives and in spite of favourable pharmaco-economic aspect.
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Abstract
AbstractThe mortality rate from cardiovascular diseases is high in Serbia. Analysis of antihypertensive drugs utilization is the basis for assessment of cardiovascular pharmacotherapy appropriateness. The aim of this study was to analyze the trend in antihypertensive drugs utilization among outpatients in Niš region, South Serbia compared to some Nordic countries (Norvay, Sweden) and Australia as well as to analyze trends in educational and drug promotion activities directed to primary healthcare workers within the same region. Using the ATC/DDD methodology, we analyzed the utilization of antihypertensive drugs dispensed on prescription in the Nis region over the 2003–2007 period. The study was retrospective, based on data obtained from Central City Pharmacy Nis. Educational and drug promotion activities were noted from the records of Medical Faculty, University of Nis, and from the records of local branches of pharmaceutical companies active in Serbia. Wilcoxon’s test was used in order to calculate the statistical significance of difference. A significant increase of 79.8% (153.8/ 276.6 DDD/inhabitants/day) in antihypertensive drug consumption was observed in the same period. This analysis showed there were substantial increases in the use of diuretics (134.7%), ACE inhibitors (79.5%) and calcium channel blockers (116.1%), especially amlodipin (241.2%). During the observed period, annual numbers of educational activities and of pharmaceutical sales representatives employed within the region increased for almost one fourth. This analysis pointed to a significant increase in the use of antihypertensive drugs in the Nis region, which was matched with increase in educational and drug promotion activities within the region, so that in 2006–2007 total consumption was approximate to some referential countries (Norvay, Sweden).
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Chang CL, Mills GD, McLachlan JD, Karalus NC, Hancox RJ. Cardio-selective and non-selective beta-blockers in chronic obstructive pulmonary disease: effects on bronchodilator response and exercise. Intern Med J 2009; 40:193-200. [PMID: 19383058 DOI: 10.1111/j.1445-5994.2009.01943.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) often have co-existing cardiovascular disease and may require beta-blocker treatment. There are limited data on the effects of beta-blockers on the response to inhaled beta2-agonists and exercise capacity in patients with COPD. OBJECTIVE To determine the effects of different doses of cardio-selective and non-selective beta-blockers on the acute bronchodilator response to beta-agonists in COPD, and to assess their effects on exercise capacity. METHODS A double-blind, randomized, three-way cross-over (metoprolol 95 mg, propranolol 80 mg, placebo) study with a final open-label high-dose arm (metoprolol 190 mg). After 1 week of each treatment, the bronchodilator response to salbutamol was measured after first inducing bronchoconstriction using methacholine. Exercise capacity was assessed using the incremental shuttle walk test. RESULTS Eleven patients with moderate COPD were recruited. Treatments were well-tolerated although two did not participate in the high-dose metoprolol phase. The area under the salbutamol-response curve was lower after propranolol compared with placebo (P=0.0006). The area under the curve also tended to be lower after high-dose metoprolol (P=0.076). The per cent recovery of the methacholine-induced fall was also lower after high-dose metoprolol (P=0.0018). Low-dose metoprolol did not alter the bronchodilator response. Oxygen saturation at peak exercise was lower with all beta-blocker treatments (P=0.046). CONCLUSION Non-selective beta-blockers and high doses of cardio-selective beta-blockers may inhibit the bronchodilator response to beta2-agonists in patients with COPD. Beta-blockers were also associated with lower oxygen saturation during exercise. The clinical significance of these adverse effects is uncertain in view of the benefits of beta-blocker treatment for cardiovascular disease.
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Affiliation(s)
- C L Chang
- Respiratory Research Unit, Department of Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand
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The effects of aspirin and nonselective beta blockade on the acute prothrombotic response to psychosocial stress in apparently healthy subjects. J Cardiovasc Pharmacol 2008; 51:231-8. [PMID: 18356686 DOI: 10.1097/fjc.0b013e318161ea63] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We hypothesized that the 2 cardiovascular drugs aspirin and propranolol attenuate the prothrombotic response to acute psychosocial stress relative to placebo medication. We randomized 56 healthy subjects, double-blind, to 5-day treatment with an oral dose of either 100 mg of aspirin plus 80 mg of propranolol combined, single aspirin, single propranolol, or placebo medication. Thereafter, subjects underwent a 13-minute psychosocial stressor. Plasma levels of von Willebrand factor antigen (VWF:Ag), fibrinogen, coagulation factor VII (FVII:C) and XII (FXII:C) activity, and D-dimer were determined in blood samples collected immediately pre- and post-stress and 45 minutes post-stress. The stress-induced changes in prothrombotic measures were adjusted for gender, age, body mass index, mean arterial blood pressure, smoking status, and sleep quality. There was an increase in VWF:Ag levels from immediately pre-stress to 45 minutes post-stress in the placebo group relative to the 3 subject groups with verum medication (P's </= 0.019; relative increase in VWF:Ag between 17% and 21%); however, the VWF:Ag response to stress was not significantly different between the three groups with verum medication. The stress responses in fibrinogen, FVII:C, FXII:C, and D-dimer were similar in all 4 medication groups. The combination of aspirin with propranolol, single aspirin, and single propranolol all attenuated the acute response in plasma VWF:Ag levels to psychosocial stress. This suggests that these cardiovascular drugs might exert limited protection from the development of stress-triggered coronary thrombosis.
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Hermanides R, Ottervanger JP. Treatment of ST-elevation myocardial infarction. Future Cardiol 2008; 4:391-7. [PMID: 19804319 DOI: 10.2217/14796678.4.4.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In patients with ST-segment elevation myocardial infarction (STEMI), timely and adequate treatment may improve the prognosis dramatically. Restoration of the infarct vessel patency is one of the cornerstones of initial treatment. Compared with fibrinolytic therapy, primary percutaneous coronary intervention (PCI) results in improved short- and long-term survival, a lower incidence of recurrent infarction and a better left ventricular function. Although (drug-eluting) stents may reduce restenosis, effects on mortality are less clear. Administration of glycoprotein IIb/IIIa antagonists may further reduce periprocedural coronary complications, but bivalirudin may offer similar effects with less bleeding. beta-adrenergic blockers, angiotensin-converting-enzyme inhibitors and statins should be initiated in all patients with STEMI, although cautious use of beta-blockers is advised in patients at risk of cardiac shock. Patients with diabetes should receive optimal glucose control. High-risk patients, particularly those with a low ejection fraction, should receive an implantable cardioverter defibrillator after 30 days, although it is not clear whether patients who have received primary PCI also benefit, particularly if they have no signs of heart failure.
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Affiliation(s)
- Rik Hermanides
- Isala klinieken, Department of Cardiology, Groot Wezenland 20, 8011 JW Zwolle, The Netherlands
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Alvarez Guisasola F, Tofé Povedano S, Krishnarajah G, Lyu R, Mavros P, Yin D. Hypoglycaemic symptoms, treatment satisfaction, adherence and their associations with glycaemic goal in patients with type 2 diabetes mellitus: findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) Study. Diabetes Obes Metab 2008; 10 Suppl 1:25-32. [PMID: 18435671 DOI: 10.1111/j.1463-1326.2008.00882.x] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS This study was undertaken to evaluate (i) factors associated with patient-reported hypoglycaemia; (ii) association of patient-reported hypoglycaemic symptoms with treatment satisfaction and barriers to adherence and (iii) association between treatment satisfaction, adherence and glycaemic control among patients with type 2 diabetes who added a sulphonylurea or a thiazolidinedione to ongoing metformin. METHODS This observational, cross-sectional, multicentre study was conducted in seven countries (Finland, France, Germany, Norway, Poland, Spain and UK) from June 2006 to February 2007. Patients with type 2 diabetes who added a sulphonylurea or a thiazolidinedione to ongoing metformin therapy on a date (index date) from January 2001 through January 2006 and who had at least one haemoglobin A1C (HbA1C) measurement in the 12-month period before the visit date were eligible. Questionnaires were used to ascertain patients' reports of hypoglycaemic symptoms, treatment satisfaction, and treatment adherence. The Treatment Satisfaction Questionnaire for Medication was used to measure patients' treatment satisfaction. An adherence and barriers questionnaire was used to measure patients' adherence to treatment. Glycaemic control was based on documented HbA1C measurements within the prior 12 months. RESULTS The mean +/- s.d. age was 62.9 +/- 10.6 years, and the mean +/- s.d. duration of diabetes was 7.8 +/- 5.1 years. HbA1C in this population of patients who had failed metformin monotherapy and were treated with oral antihyperglycaemic agents was below the International Diabetes Federation goal of 6.5% in only 477 (27.9%) patients. Approximately 38% of patients reported hypoglycaemic symptoms during the past year. Hypoglycaemia was significantly more likely in patients with a history of macrovascular complications of diabetes (OR = 1.346; 95% CI = 1.050-1.725) and with no regular physical activity (OR = 1.295; 95% CI = 1.037-1.618). Patients reporting hypoglycaemia had significantly lower treatment satisfaction scores (71.6 +/- 17.6 vs. 76.3 +/- 16.8; p < 0.0001 for global satisfaction). Compared with their counterparts reporting no hypoglycaemic symptoms, patients with such symptoms were also significantly more likely to report barriers to adherence, including being unsure about instructions (37.0 vs. 30.5%; p = 0.0057). Patients at HbA1C goal had significantly higher treatment satisfaction and adherence compared with those who were not. CONCLUSIONS Patients' reports of hypoglycaemic symptoms are common in European outpatients with type 2 diabetes and are associated with significantly lower treatment satisfaction and with barriers to adherence. In addition, being at HbA1C goal is associated with treatment satisfaction and adherence.
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Long-term adherence to evidence based secondary prevention therapies after acute myocardial infarction. J Gen Intern Med 2008; 23:115-21. [PMID: 17922172 PMCID: PMC2359158 DOI: 10.1007/s11606-007-0351-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Revised: 12/27/2006] [Accepted: 08/16/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND After acute myocardial infarction (AMI), treatment with beta-blockers and angiotensin-converting enzyme inhibitors (ACEI) is widely recognized as crucial to reduce risk of a subsequent AMI. However, many patients fail to consistently remain on these treatments over time, and long-term adherence has not been well described. OBJECTIVE To examine the duration of treatment with beta-blockers and ACEI within the 24 months after an AMI. DESIGN A retrospective, observational study using medical and pharmacy claims from a large health plan operating in the Northeastern United States. SUBJECTS Enrollees with an inpatient claim for AMI who initiated beta-blocker (N = 499) or ACEI (N = 526) therapy. MEASUREMENT Time from initiation to discontinuation was measured with pharmacy refill records. Associations between therapy discontinuation and potential predictors were estimated using a Cox proportional hazards model. RESULTS ACEI discontinuation rates were high: 7% stopped within 1 month, 22% at 6 months, 32% at 1 year and 50% at 2 years. Overall discontinuation rates for beta-blockers were similar, but predictors of discontinuation differed for the two treatment types. For beta-blockers, the risk of discontinuation was highest among males and those from low-income neighborhoods; patients with comorbid hypertension and peripheral vascular disease were less likely to discontinue therapy. These factors were not associated with ACEI discontinuation. CONCLUSION Many patients initiating evidence-based secondary prevention therapies after an AMI fail to consistently remain on these treatments. Adherence is a priority area for development of better-quality measures and quality-improvement interventions. Barriers to beta-blocker adherence for low-income populations need particular attention.
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Saunders E, Smith WB, DeSalvo KB, Sullivan WA. The efficacy and tolerability of nebivolol in hypertensive African American patients. J Clin Hypertens (Greenwich) 2007; 9:866-75. [PMID: 17978594 DOI: 10.1111/j.1524-6175.2007.07548.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hypertensive African Americans often respond poorly to beta-blocker monotherapy, compared with whites. There is evidence, however, that suggests that this response may be different if beta-blockers with vasodilating effects are used. This 12-week, multi-center, double-blind, randomized placebo-controlled study assessed the antihypertensive efficacy and safety of nebivolol, a cardioselective, vasodilating beta1-blocker, at doses of 2.5, 5, 10, 20, or 40 mg once daily in 300 African American patients with stage I or II hypertension (mean sitting diastolic blood pressure [SiDBP] > or =95 mm Hg and < or =109 mm Hg). The primary efficacy end point was the baseline-adjusted change in trough mean SiDBP. After 12 weeks, nebivolol significantly reduced least squares mean SiDBP (P< or =.004) at all doses of 5 mg and higher and sitting systolic blood pressure (P< or =.044) at all doses 10 mg and higher, compared with placebo. The drug was safe and well-tolerated, with no significant difference in the incidence of adverse events compared with placebo. Nebivolol monotherapy provides antihypertensive efficacy, with few significant adverse effects, in hypertensive African Americans.
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Affiliation(s)
- Elijah Saunders
- Section of Hypertension, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Roberts WC, Black HR, Bakris GL, Mason RP, Giles TD, Sulkes DJ. The editor's roundtable: revisiting the role of beta blockers in hypertension. Am J Cardiol 2007; 100:253-67. [PMID: 17631080 DOI: 10.1016/j.amjcard.2007.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 03/28/2007] [Indexed: 11/23/2022]
Affiliation(s)
- William C Roberts
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA.
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Berry C, Tardif JC, Bourassa MG. Coronary Heart Disease in Patients With Diabetes. J Am Coll Cardiol 2007; 49:631-42. [PMID: 17291928 DOI: 10.1016/j.jacc.2006.09.046] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Revised: 09/07/2006] [Accepted: 09/11/2006] [Indexed: 12/25/2022]
Abstract
Diabetes mellitus (DM) is a worldwide epidemic. Its prevalence is rapidly increasing in both developing and developed countries. Coronary heart disease (CHD) is highly prevalent and is the major cause of morbidity and mortality in diabetic patients. The purpose of this review is to assess the clinical impact of recent advances in the epidemiology, prevention, and management of CHD in diabetic patients. A systematic review of publications in this area, referenced in MEDLINE in the past 5 years (2000 to 2005), was undertaken. Patients with CHD and prediabetic states should undergo lifestyle modifications aimed at preventing DM. Pharmacological prevention of DM is also promising but requires further study. In patients with CHD and DM, routine use of aspirin and an angiotensin-converting enzyme inhibitor (ACE-I)--unless contraindicated or not tolerated-and strict glycemic, blood pressure, and lipid control are strongly recommended. The targets for secondary prevention in these patients are relatively well defined, but the strategies to achieve them vary and must be individualized. Intense insulin therapy might be needed for glycemic control, and high-dose statin therapy might be needed for lipid control. For blood pressure control, ACE-Is and angiotensin receptor blockers are considered as first-line therapy. Noncompliance, particularly with lifestyle measures, and underprescription of evidence-based therapies remain important unsolved problems.
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Affiliation(s)
- Colin Berry
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
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van Melle JP, Verbeek DEP, van den Berg MP, Ormel J, van der Linde MR, de Jonge P. Beta-Blockers and Depression After Myocardial Infarction. J Am Coll Cardiol 2006; 48:2209-14. [PMID: 17161247 DOI: 10.1016/j.jacc.2006.07.056] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Revised: 07/12/2006] [Accepted: 07/24/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The purpose of this research was to explore the prospective relationship between the use of beta-blockers and depression in myocardial infarction (MI) patients. BACKGROUND Beta-blocker use has been reported to be associated with the development of depression, but the methodological quality of studies in this field is weak. METHODS In a multicenter study, MI patients (n = 127 non-beta-blocker users and n = 254 beta-blocker users) were assessed for depressive symptoms (using the Beck Depression Inventory [BDI] at baseline and t = 3, 6, and 12 months post-MI) and International Classification of Diseases-10 depressive disorder (Composite International Diagnostic Interview). Patients were matched using the frequency matching procedure according to age, gender, hospital of admission, presence of baseline depressive symptoms, and left ventricular function. RESULTS No significant differences were found between non-beta-blocker users and beta-blocker users on the presence of depressive symptoms (p > 0.10 at any of the time points) or depressive disorder (p = 0.86). Controlling for confounders did not alter these findings. A trend toward increasing BDI scores was seen in patients with long-term use of beta-blockers and patients with higher beta-blocker dose. CONCLUSIONS In post-MI patients, prescription of beta-blockers is not associated with an increase in depressive symptoms or depressive disorders in the first year after MI. However, long-term and high-dosage effects cannot be ruled out.
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Affiliation(s)
- Joost P van Melle
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, Groningen, The Netherlands.
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von Känel R, Begré S. Depression after myocardial infarction: unraveling the mystery of poor cardiovascular prognosis and role of beta-blocker therapy. J Am Coll Cardiol 2006; 48:2215-7. [PMID: 17161248 DOI: 10.1016/j.jacc.2006.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Yancy CW, Lopatin M, Stevenson LW, De Marco T, Fonarow GC. Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. J Am Coll Cardiol 2005; 47:76-84. [PMID: 16386668 DOI: 10.1016/j.jacc.2005.09.022] [Citation(s) in RCA: 716] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Revised: 08/17/2005] [Accepted: 09/08/2005] [Indexed: 02/07/2023]
Abstract
UNLABELLED Approximately 50% of patients hospitalized for heart failure have preserved systolic function. These patients are more likely to be older, women, and hypertensive. Their duration of hospitalization is similar to that of heart failure patients with systolic dysfunction, but their in-hospital mortality risk is lower. This mortality risk is increased in the setting of renal insufficiency, and the two most important risk predictors are elevated blood urea nitrogen and systolic blood pressure < or = 125 mm Hg. Medical treatment strategies for patients with preserved systolic function are inconsistent and reflect the need for efficacious evidence-based treatment regimens. OBJECTIVES The aims of this analysis were to describe the clinical characteristics, management, and outcomes of patients hospitalized for acute decompensated heart failure (HF) with preserved systolic function (PSF). BACKGROUND Clinically meaningful characteristics of these patients have not been fully studied in a large database. METHODS Data from >100,000 hospitalizations from the Acute Decompensated Heart Failure National Registry (ADHERE) database were analyzed. RESULTS Heart failure with PSF was present in 50.4% of patients with in-hospital assessment of left ventricular function. When compared with patients with systolic dysfunction, patients with PSF were more likely to be older, women, and hypertensive and less likely to have had a prior myocardial infarction or be receiving an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker. In-hospital mortality was lower in patients with PSF compared with patients with systolic dysfunction (2.8% vs. 3.9%; adjusted odds ratio [OR]: 0.86; p = 0.005), but duration of intensive care unit stay and total hospital length of stay were similar. Serum creatinine >2 mg/dl was associated with increased in-hospital mortality in both systolic function groups (PSF: 4.8%; systolic dysfunction: 8.4%; p < 0.0001), and the most powerful predictors of in-hospital mortality in both groups were blood urea nitrogen >37 mg/dl (OR: 2.53; 95% confidence interval [CI]: 2.22 to 2.87) and systolic blood pressure < or =125 mm Hg (OR: 2.58; 95% CI: 2.33 to 2.86). CONCLUSIONS Heart failure with PSF is common and is characterized by a unique patient profile. Event rates are worrisome and reflect a need for more effective management strategies.
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Affiliation(s)
- Clyde W Yancy
- Division of Cardiology, Department of Medicine, University of Texas Southwest Medical Center, Dallas, Texas 75390-9047, USA.
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Abstract
BACKGROUND AND OBJECTIVE Cardiovascular disease has been identified as the leading cause of morbidity and mortality in developed countries. Given the increase in life expectancy and the development of cardiovascular preventive measures, it has become increasingly important to detect and prevent cardiovascular diseases in the elderly. We reviewed the scientific literature concerning cardiovascular prevention to assess the importance of cardiovascular preventive measures in old (> or =65 years of age) individuals. METHODS We undertook a systematic search for references relating to prevention of cardiovascular disease in the elderly, mainly ischaemic stroke, coronary artery disease and heart failure, on the MEDLINE database 1962-2005. For cardiovascular prevention by drugs or surgery, emphasis was placed on randomised controlled trials, review articles and meta-analyses. For cardiovascular prevention by lifestyle modification, major cohort studies were also considered. RESULTS Stroke, coronary heart disease and heart failure were found to be the main targets for cardiovascular prevention in published studies. Antihypertensive treatment has proven its efficacy in primary prevention of fatal or nonfatal stroke in hypertensive and high-risk patients >60 years of age, particularly through treatment of systolic hypertension. Systolic blood pressure reduction is equally important in the secondary prevention of stroke. Similarly, in nonvalvular atrial fibrillation, an adjusted dose of warfarin with a target International Normalized Ratio (INR) of between 2 to 3 prevents ischaemic stroke in elderly patients with an acceptable haemorrhagic risk but is still under prescribed. Antiplatelet agents are indicated in elderly patients with nonembolic strokes. Few large-scale studies have investigated the effect of HMG-CoA reductase inhibitors (statins) on stroke prevention in old individuals. To date, the largest trials suggest a beneficial effect for stroke prevention with use of statins in high-risk elderly subjects < or =82 years of age. Carotid endarterectomy is indicated in carotid artery stenosis >70% and outcomes are even better in elderly than in younger patients. However, medical treatment is still the first-line treatment in asymptomatic elderly patients with <70% stenosis. In ischaemic heart disease, different trials in elderly individuals have shown that use of statins, antithrombotic agents, beta-adrenoceptor antagonists and ACE inhibitors plays an important role either in primary or in secondary cardiovascular prevention. Hormone replacement therapy has been used to treat climacteric symptoms and postmenopausal osteoporosis and was thought to confer a cardiovascular protection. However, controlled trials in elderly individuals changed this false belief when it was found that there was no benefit and even a harmful cardiovascular effect during the first year of treatment. Smoking cessation, regular physical activity and healthy diet are, as in younger individuals, appropriate and effective measures for preventing cardiovascular events in the elderly. Finally, antihypertensive treatment and influenza vaccination are useful for heart failure prevention in elderly individuals. CONCLUSIONS Cardiovascular prevention should be more widely implemented in the elderly, including individuals aged > or =75 years, and this might contribute to improved healthy status and quality of life in this growing population.
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Affiliation(s)
- Wafik Farah Andrawes
- Service de Gériatrie, Hôpital Charles Foix et Université Paris 6, Ivry-sur-Seine, France
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