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Kang Y, Qu N, Zhang Z, Zhang Q, Chen X, Fu M. Tolerability and effectiveness of beta-blockers in patients with cardiac amyloidosis: A systematic review and meta-analysis. Int J Cardiol 2024; 402:131813. [PMID: 38278490 DOI: 10.1016/j.ijcard.2024.131813] [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: 11/27/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE This systematic review aimed to assess the tolerability of patients with cardiac amyloidosis (CA) to beta-blockers (BBs) and evaluate its association with adverse outcomes. METHODS We performed a comprehensive search from January 1, 2000 to October 20, 2023. Studies examining BB use and tolerance or the relationship between BB use and outcomes in patients with CA were included. Pooled adjusted hazard ratios (aHRs) for all-cause mortality were calculated using random- and fixed-effects models. RESULTS Eight observational studies involving 4002 patients with CA (87.5% with transthyretin CA [ATTR-CA] and 12.5% with immunoglobulin light chain CA [AL-CA]) were assessed. BBs were used by 52.5% of the patients. However, 26.3% of the patients discontinued BBs because of hypotension, bradycardia, or fatigue. Regarding the association between BB use and all-cause death, four studies were identified that included 2874 patients with ATTR-CA and 16 patients with AL-CA. The meta-analysis revealed no apparent relationship between BB use and all-cause mortality (pooled aHR = 0.78, 95% confidence interval (CI) = 0.40-1.51). Two studies on patients with ATTR-CA found no impact of BB use on all-cause mortality in the subgroup with left ventricular ejection fraction (LVEF) > 40%, but conflicting results exist for those with LVEF ≤40% (pooled aHR = 0.78, 95% CI = 0.40-1.54). CONCLUSION The limited number of observational studies that predominantly enrolled patients with ATTR-CA showed that BBs were used in almost half of the patients with CA, with varying tolerability. However, no significant association was observed between BB use and all-cause mortality.
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Affiliation(s)
- Yu Kang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Nan Qu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhongyin Zhang
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaojing Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Parrini I, Lucà F, Rao CM, Cacciatore S, Riccio C, Grimaldi M, Gulizia MM, Oliva F, Andreotti F. How to Manage Beta-Blockade in Older Heart Failure Patients: A Scoping Review. J Clin Med 2024; 13:2119. [PMID: 38610883 PMCID: PMC11012494 DOI: 10.3390/jcm13072119] [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: 02/29/2024] [Revised: 03/22/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Beta blockers (BBs) play a crucial role in enhancing the quality of life and extending the survival of patients with heart failure and reduced ejection fraction (HFrEF). Initiating the therapy at low doses and gradually titrating the dose upwards is recommended to ensure therapeutic efficacy while mitigating potential adverse effects. Vigilant monitoring for signs of drug intolerance is necessary, with dose adjustments as required. The management of older HF patients requires a case-centered approach, taking into account individual comorbidities, functional status, and frailty. Older adults, however, are often underrepresented in randomized clinical trials, leading to some uncertainty in management strategies as patients with HF in clinical practice are older than those enrolled in trials. The present article performs a scoping review of the past 25 years of published literature on BBs in older HF patients, focusing on age, outcomes, and tolerability. Twelve studies (eight randomized-controlled and four observational) encompassing 26,426 patients were reviewed. The results indicate that BBs represent a viable treatment for older HFrEF patients, offering benefits in symptom management, cardiac function, and overall outcomes. Their role in HF with preserved EF, however, remains uncertain. Further research is warranted to refine treatment strategies and address specific aspects in older adults, including proper dosing, therapeutic adherence, and tolerability.
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Affiliation(s)
- Iris Parrini
- Department of Cardiology, Mauriziano Hospital, Largo Filippo Turati, 62, 10128 Turin, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Via Melacrino 1, 89124 Reggio Calabria, Italy;
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Via Melacrino 1, 89124 Reggio Calabria, Italy;
| | - Stefano Cacciatore
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, Via Ferdinando Palasciano, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | | | - Fabrizio Oliva
- “A. De Gasperis” Cardiovascular Department, Division of Cardiology, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy;
| | - Felicita Andreotti
- Cardiovascular and Respiratory Sciences, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168 Rome, Italy;
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Gallo G, Volpe M. Potential Mechanisms of the Protective Effects of the Cardiometabolic Drugs Type-2 Sodium-Glucose Transporter Inhibitors and Glucagon-like Peptide-1 Receptor Agonists in Heart Failure. Int J Mol Sci 2024; 25:2484. [PMID: 38473732 DOI: 10.3390/ijms25052484] [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: 01/15/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Different multifactorial pathophysiological processes are involved in the development of heart failure (HF), including neurohormonal dysfunction, the hypertrophy of cardiomyocytes, interstitial fibrosis, microvascular endothelial inflammation, pro-thrombotic states, oxidative stress, decreased nitric oxide (NO) bioavailability, energetic dysfunction, epicardial coronary artery lesions, coronary microvascular rarefaction and, finally, cardiac remodeling. While different pharmacological strategies have shown significant cardiovascular benefits in HF with reduced ejection fraction (HFrEF), there is a residual unmet need to fill the gap in terms of knowledge of mechanisms and efficacy in the outcomes of neurohormonal agents in HF with preserved ejection fraction (HFpEF). Recently, type-2 sodium-glucose transporter inhibitors (SGLT2i) have been shown to contribute to a significant reduction in the composite outcome of HF hospitalizations and cardiovascular mortality across the entire spectrum of ejection fraction. Moreover, glucagon-like peptide-1 receptor agonists (GLP1-RA) have demonstrated significant benefits in patients with high cardiovascular risk, excess body weight or obesity and HF, in particular HFpEF. In this review, we will discuss the biological pathways potentially involved in the action of SGLT2i and GLP1-RA, which may explain their effective roles in the treatment of HF, as well as the potential implications of the use of these agents, also in combination therapies with neurohormonal agents, in the clinical practice.
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Affiliation(s)
- Giovanna Gallo
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Via di Grottarossa 1035-1039, 00189 Rome, Italy
| | - Massimo Volpe
- IRCCS San Raffaele Roma, Via della Pisana 235, 00163 Rome, Italy
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Manolis AA, Manolis TA, Manolis AS. Neurohumoral Activation in Heart Failure. Int J Mol Sci 2023; 24:15472. [PMID: 37895150 PMCID: PMC10607846 DOI: 10.3390/ijms242015472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/16/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
In patients with heart failure (HF), the neuroendocrine systems of the sympathetic nervous system (SNS), the renin-angiotensin-aldosterone system (RAAS) and the arginine vasopressin (AVP) system, are activated to various degrees producing often-observed tachycardia and concomitant increased systemic vascular resistance. Furthermore, sustained neurohormonal activation plays a key role in the progression of HF and may be responsible for the pathogenetic mechanisms leading to the perpetuation of the pathophysiology and worsening of the HF signs and symptoms. There are biomarkers of activation of these neurohormonal pathways, such as the natriuretic peptides, catecholamine levels and neprilysin and various newer ones, which may be employed to better understand the mechanisms of HF drugs and also aid in defining the subgroups of patients who might benefit from specific therapies, irrespective of the degree of left ventricular dysfunction. These therapies are directed against these neurohumoral systems (neurohumoral antagonists) and classically comprise beta blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers and vaptans. Recently, the RAAS blockade has been refined by the introduction of the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan, which combines the RAAS inhibition and neprilysin blocking, enhancing the actions of natriuretic peptides. All these issues relating to the neurohumoral activation in HF are herein reviewed, and the underlying mechanisms are pictorially illustrated.
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Affiliation(s)
- Antonis A Manolis
- First Department of Cardiology, Evagelismos Hospital, 106 76 Athens, Greece
| | - Theodora A Manolis
- Department of Psychiatry, Aiginiteio University Hospital, 115 28 Athens, Greece
| | - Antonis S Manolis
- First Department of Cardiology, Ippokrateio University Hospital, 115 27 Athens, Greece
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Ishibashi T, Morita S, Furuta H, Nishi M, Matsuoka TA. Renoprotective potential of concomittant medications with SGLT2 inhibitors and renin-angiotensin system inhibitors in diabetic nephropathy without albuminuria: a retrospective cohort study. Sci Rep 2023; 13:16373. [PMID: 37773087 PMCID: PMC10541410 DOI: 10.1038/s41598-023-43614-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/26/2023] [Indexed: 09/30/2023] Open
Abstract
The renal protective effects of sodium-glucose co-transporter 2 (SGLT2) inhibitors and renin-angiotensin system (RAS) inhibitors on diabetic nephropathy without albuminuria have not been fully investigated. This retrospective cohort study focused on patients with type 2 diabetes mellitus who had a baseline estimated glomerular filtration rate (eGFR) of > 30 mL/min/1.73 m2, and a urinary albumin-to-creatinine ratio < 30 mg/gCr. After propensity score matching, using covariates such as age, body mass index, systolic blood pressure, hemoglobin A1c levels, and prescription history of RAS inhibitors, we established a cohort of 58 patients: the SGLT2 inhibitor group (n = 28) and the control group (n = 28). In this cohort, we compared the annual eGFR decline rate between the two groups. The SGLT2 inhibitor group exhibited a significantly smaller eGFR change than the control group (- 1.15 vs. - 2.18 mL/min/1.73 m2/year). Within the SGLT2 inhibitor group, patients prescribed RAS inhibitors had demonstrated an even smaller eGFR change (- 0.70 mL/min/1.73 m2/year). In conclusion, SGLT2 inhibitors also have safeguarding effects in the stage of diabetic nephropathy without albuminuria, and the combined use of a SGLT2 inhibitor and a RAS inhibitor appears to be more effective than the single use of each.
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Affiliation(s)
- Tatsuya Ishibashi
- First Department of Medicine, Wakayama Medical University, 811‑1 Kimi‑idera, Wakayama City, Wakayama, 641‑8509, Japan.
| | - Shuhei Morita
- First Department of Medicine, Wakayama Medical University, 811‑1 Kimi‑idera, Wakayama City, Wakayama, 641‑8509, Japan
| | - Hiroto Furuta
- First Department of Medicine, Wakayama Medical University, 811‑1 Kimi‑idera, Wakayama City, Wakayama, 641‑8509, Japan
| | - Masahiro Nishi
- Department of Medical Technology, Faculty of Health Sciences, Kansai University of Health Sciences, Sennan, Osaka, Japan
| | - Taka-Aki Matsuoka
- First Department of Medicine, Wakayama Medical University, 811‑1 Kimi‑idera, Wakayama City, Wakayama, 641‑8509, Japan
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