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Humphries S, Mars K, Hofmann R, Held C, Olsson EMG. Randomized evaluation of routine beta-blocker therapy after myocardial infarction quality of life (RQoL): design and rationale of a multicentre, prospective, randomized, open, blinded endpoint study. Eur Heart J Open 2023; 3:oead036. [PMID: 37265820 PMCID: PMC10230287 DOI: 10.1093/ehjopen/oead036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/09/2023] [Indexed: 06/03/2023]
Abstract
Aims Most cases of acute myocardial infarction (MI) in Sweden are treated with long-term β-blocker therapy as secondary prevention. Case studies and patient reports have indicated negative effects of β-blockers including symptoms of depression, fatigue, sexual dysfunction, and general low mood, all related to reduced quality of life (QoL). To date, no recent large-scale, randomized trial has explored the effects of β-blockers on these factors. Methods and results The ongoing Randomized Evaluation of Decreased Usage of beta-bloCkErs after myocardial infarction (REDUCE): quality of life (RQoL) study is a multicentre, prospective, randomized pre-specified substudy aiming to evaluate the effects of β-blockers on self-reported measures of QoL. Following randomized allocation to long-term β-blocker or no β-blocker treatment, patients complete a total of six baseline measures pertaining to QoL, sexual functioning, and perceived side effects. Data collection is optionally carried out online through a unique and secure portal and repeated again at two follow-up time points. Recruitment began in July 2018. Data from the first 100 patients showed that at the first follow-up, 93% had completed the questionnaires, which decreased to 81% at the second follow-up. The method of digital data collection was utilized by over half of the patients recruited so far. Conclusion Data from the first 100 patients indicate success in terms of study design and recruitment. The RQoL substudy investigates the effects of β-blockers on self-reported measures of QoL in MI patients and will potentially contribute to the limited knowledge of QoL-related side effects reported in conjunction with β-blocker use. Clinical trial registration Eudra CT number, 2017-002336-17; Clinical trial.gov identifier, NCT03278509.
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Affiliation(s)
| | - Katarina Mars
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institute, Stockholm, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institute, Stockholm, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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Abstract
When the coronavirus disease 2019 (COVID-19) pandemic spread globally from the Hubei region of China in December 2019, the impact on elderly people was particularly unfavorable. The mortality associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was highest in older individuals, in whom frailty and comorbidities increased susceptibility to severe forms of COVID-19. Unfortunately, in older patients, the course of COVID-19 was often characterized by significant cardiovascular complications, such as heart failure decompensation, arrhythmias, pericarditis, and myopericarditis. Ensuring that the elderly have adequate therapeutic coverage against known cardiovascular diseases and risk factors is particularly important in the COVID-19 era. Beta blockers are widely used for the treatment and prevention of cardiovascular disease. The clinical benefits of beta blockers have been confirmed in elderly patients, and in addition to their negative chronotropic effect, sympathetic inhibition and anti-inflammatory activity are theoretically of great benefit for the treatment of COVID-19 infection. Beta blockers have not been clearly shown to prevent SARS-CoV-2 infection, but there is evidence from published studies including elderly patients that beta blockers are associated with a more favorable clinical course of COVID-19 and reduced mortality. In this minireview, we summarize the most important evidence available in the literature on the usefulness of beta blocker therapy for older patients in the context of the COVID-19 pandemic.
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Affiliation(s)
- Elpidio Santillo
- Geriatric Rehabilitative Department, IRCCS-INRCA, Fermo 63900, Italy
| | - Monica Migale
- Geriatric Rehabilitative Department, IRCCS-INRCA, Fermo 63900, Italy
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Mars K, Wallert J, Held C, Humphries S, Pingel R, Jernberg T, Olsson EMG, Hofmann R. Association between β-blocker dose and cardiovascular outcomes after myocardial infarction: insights from the SWEDEHEART registry. Eur Heart J Acute Cardiovasc Care 2020; 10:372-379. [PMID: 33620439 DOI: 10.1093/ehjacc/zuaa002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/15/2020] [Accepted: 07/24/2020] [Indexed: 12/17/2022]
Abstract
AIMS Dose-dependent effects of β-blockers on survival and cardiovascular outcomes after myocardial infarction (MI) are not well understood. We investigated the long-term risk of cardiovascular events in patients with different doses of β-blockers after MI. METHODS AND RESULTS This was a nationwide observational study linking morbidity, mortality, socioeconomic, and medication data from Swedish national registries. Between 2006 and 2015, 97 575 unique patients with first-time MI were included. In total, 33 126 (33.9%) patients were discharged with ≥50% of the target β-blocker dose and 64 449 (66.1%) patients with <50% of the target β-blocker dose used in previous randomized trials. The primary composite endpoint was re-infarction or all-cause death within 1 year from discharge. Multivariable adjusted 1-year follow-up estimates using mixed effects Cox regression [HR (95% CI)] showed that patients treated with ≥50% of the target dose had a similar risk of the composite endpoint [1.03 (0.99-1.08)] and a somewhat higher risk when stroke, atrial fibrillation, or heart failure hospitalization were added to the composite endpoint [1.08 (1.04-1.12)], compared with patients on <50% of the target β-blocker dose. Results remained similar up to 5 years of follow-up and consistent across relevant patient subgroups, including patients who developed heart failure during the index hospitalization. CONCLUSIONS In contrast to doses of β-blockers used in previous trials, ≥50% of the target β-blocker dose was not associated with superior cardiovascular outcomes up to 5 years as compared with <50% of the target dose. Contemporary randomized clinical trials are needed to clarify the optimal dose of β-blockers after MI.
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Affiliation(s)
- Katarina Mars
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, 11883 Stockholm, Sweden
| | - John Wallert
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, 113 64 Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, 751 85 Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, 751 85 Uppsala, Sweden
| | - Sophia Humphries
- Department of Women's and Children's Health, Uppsala University, 751 85 Uppsala, Sweden
| | - Ronnie Pingel
- Department of Statistics, Uppsala University, 751 20 Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 182 88 Stockholm, Sweden
| | - Erik M G Olsson
- Department of Women's and Children's Health, Uppsala University, 751 85 Uppsala, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, 11883 Stockholm, Sweden
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Kiyokuni M, Konishi M, Saigusa Y, Iwata K, Nakayama N, Komura N, Sugano T, Ishigami T, Ishikawa T, Yamanaka T, Tamura K, Kimura K. Randomized controlled trial of landiolol, a short-acting beta-1 adrenergic receptor blocker, illustrating changes in high-molecular weight adiponectin levels after elective percutaneous coronary intervention. Heart Vessels 2020; 35:1510-7. [PMID: 32533314 DOI: 10.1007/s00380-020-01637-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
Adiponectin (APN) has cardioprotective properties and bisoprolol has been reported to increase myocardial APN expression and reduce myocardial damage. Administration of landiolol, which has a higher cardio-selectivity and shorter half-life than bisoprolol, during the percutaneous coronary intervention (PCI) may increase serum APN and high-molecular weight (HMW)-APN, an active form of APN, in patients with stable angina pectoris (SAP). We recruited 70 patients with SAP and randomized them to intravenous landiolol during PCI (N = 35) or control group (N = 35). The primary endpoint was serum APN and HMW-APN level 3 days after PCI. There was no difference in the primary endpoint between the landiolol and control groups (8.93 ± 5.24 vs. 10.18 ± 5.81 μg/mL, p = 0.35 and 3.36 ± 2.75 vs. 4.28 ± 3.13 μg/mL, p = 0.20) for APN and HMW-APN levels, respectively. APN and HMW-APN level were significantly decreased 1 day after PCI [-0.55 ± 0.92 μg/mL (9.87-9.32 μg/mL), p < 0.001 and -0.20 ± 0.45 μg/mL (3.89-3.69 μg/mL), p < 0.001, respectively]. Additionally, the absolute change in HMW-APN was significantly smaller in the landiolol group compared to the control group (-0.08 ± 0.27 vs. -0.31 ± 0.55 μg/mL, p = 0.031). Multiple linear regression analysis showed that use of landiolol was an independent predictor of change in HMW-APN (β = 0.276, p = 0.014). Serum APN and HMW-APN level 3 days after PCI were similar between patients treated with and without landiolol. APN and HMW-APN decreased 1 day after PCI in the SAP and landiolol mitigated decrease in HMW-APN.
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Kim SH, Yun SC, Park JJ, Lee SE, Jeon ES, Kim JJ, Cho MC, Chae SC, Kang SM, Choi DJ, Yoo BS, Kim KH, Oh BH, Baek SH. Beta-Blockers in Patients with Heart Failure with Preserved Ejection Fraction: Results from The Korea Acute Heart Failure (KorAHF) Registry. Korean Circ J 2018; 49:238-248. [PMID: 30468042 PMCID: PMC6393317 DOI: 10.4070/kcj.2018.0259] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/28/2018] [Accepted: 10/31/2018] [Indexed: 01/08/2023] Open
Abstract
Background and Objectives Beta-blockers are indicated in patients with heart failure (HF) with reduced ejection fraction. However, their efficacy in patients with HF with preserved ejection fraction (HFpEF) is uncertain. We investigated the hypothesis that beta-blockers are associated with reduced adverse events in patients with HFpEF. Methods The Korea Acute Heart Failure (KorAHF) is a prospective observational multicentre cohort study. The 5,625 patients hospitalized for acute HF syndrome in 10 tertiary university hospitals across the country have been consecutively enrolled between March 2011 and February 2014. Of these patients, 2,152 patients with HFpEF (ejection fraction ≥40%) were investigated. The primary outcome was all-cause mortality according to beta-blocker use. Results During a median follow-up duration of 807 days, 702 patients died. In Cox proportional hazards model beta-blocker use was associated with a 14% reduced all-cause death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.75–0.98), but not with reduce rehospitalization (HR, 1.03; 95% CI, 0.85–1.27). In the propensity-score matched population, beta-blockers were also associated with reduced all-cause death (HR, 0.80; 95% CI, 0.69–0.94) but not with reduced rehospitalization (HR, 1.08; 95% CI, 0.87–1.33). Conclusions In Korean patients with HFpEF, use of beta-blockers is associated with reduced all-cause death but not with reduced rehospitalization.
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Affiliation(s)
- Sung Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Cheol Yun
- Department of Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Joo Park
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Eun Lee
- Division of Cardiology, Heart institute, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Eun Seok Jeon
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Jae Joong Kim
- Division of Cardiology, Heart institute, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Seok Min Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung Su Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kye Hun Kim
- Department of Internal Medicine, Heart Research Center of Chonnam National University, Gwangju, Korea
| | - Byung Hee Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang Hong Baek
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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You SC, An MH, Yoon D, Ban GY, Yang PS, Yu HT, Park RW, Joung B. Rate control and clinical outcomes in patients with atrial fibrillation and obstructive lung disease. Heart Rhythm 2018; 15:1825-1832. [PMID: 30509364 DOI: 10.1016/j.hrthm.2018.06.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Rate-control medications are considered first-line treatment for patients with atrial fibrillation (AF). However, obstructive lung disease (OLD), a condition prevalent in those with AF, often makes it difficult to use those medications because of the lack of studies on new-onset AF in patients with OLD. OBJECTIVE The purpose of this study was to investigate clinical outcomes after administration of each class of rate-control medication in patients with concomitant AF and OLD (AF-OLD). METHODS This study used the entire database provided by the National Health Insurance Service from 2002 to 2015. Risk of all-cause mortality was compared between use of calcium channel blocker (CCB) and use of other drug classes in AF-OLD patients using Cox regression analyses after propensity score matching. RESULTS Among the 13,111 patients, the number of AF-OLD patients treated with a CCB, cardioselective β-blocker (BB), nonselective BB, and digoxin was 2482, 2379, 2255, and 5995, respectively. The risk of mortality was lower with use of selective BB (hazard ratio [HR] 0.84; 95% confidence interval [CI] 0.75-0.94; P = .002) and nonselective BB (HR 0.85; 95% CI 0.77-0.95; P = .003) compared to use of CCBs. Digoxin use was related with worse survival, with marginal statistical significance (HR 1.09; 95% CI 1.00-1.18; P = .053). CONCLUSION Among patients with AF-OLD, rate-control treatment using selective and nonselective BB was associated with a significant reduction in mortality compared with CCB use. Further prospective randomized trials are required to confirm these findings.
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Affiliation(s)
- Seng Chan You
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon-si, Gyeonggi-do, Korea
| | - Min Ho An
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon-si, Gyeonggi-do, Korea
| | - Dukyong Yoon
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon-si, Gyeonggi-do, Korea
| | - Ga-Young Ban
- Department of Allergy and Clinical Immunology, Ajou University Hospital, Ajou University School of Medicine, Suwon-si, Gyeonggi-do, Korea
| | - Pil-Sung Yang
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Tae Yu
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Korea
| | - Rae Woong Park
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon-si, Gyeonggi-do, Korea; Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon-si, Gyeonggi-do, Korea
| | - Boyoung Joung
- Division of Cardiology, Yonsei University College of Medicine, Seoul, Korea.
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Abstract
Epidemiological studies have demonstrated that high resting heart rates are associated with increased mortality. Clinical studies in patients with heart failure and reduced ejection fraction have shown that heart rate lowering with beta-blockers and ivabradine improves survival. It is therefore often assumed that heart rate lowering is beneficial in other patients as well. Here, we critically appraise the effects of pharmacological heart rate lowering in patients with both normal and reduced ejection fraction with an emphasis on the effects of pharmacological heart rate lowering in hypertension and heart failure. Emerging evidence from recent clinical trials and meta-analyses suggest that pharmacological heart rate lowering is not beneficial in patients with a normal or preserved ejection fraction. This has just begun to be reflected in some but not all guideline recommendations. The detrimental effects of pharmacological heart rate lowering are due to an increase in central blood pressures, higher left ventricular systolic and diastolic pressures, and increased ventricular wall stress. Therefore, we propose that heart rate lowering per se reproduces the hemodynamic effects of diastolic dysfunction and imposes an increased arterial load on the left ventricle, which combine to increase the risk of heart failure and atrial fibrillation. Pharmacologic heart rate lowering is clearly beneficial in patients with a dilated cardiomyopathy but not in patients with normal chamber dimensions and normal systolic function. These conflicting effects can be explained based on a model that considers the hemodynamic and ventricular structural effects of heart rate changes.
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Affiliation(s)
- Markus Meyer
- Department of Medicine, Cardiology Division, Larner College of Medicine at the University of Vermont, UVMMC, McClure 1, Cardiology, 111 Colchester Avenue, Burlington, VT, 05401, USA.
- Department of Medicine, Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, VT, 05405, USA.
| | - Mehdi Rambod
- Department of Medicine, Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, VT, 05405, USA
| | - Martin LeWinter
- Department of Medicine, Cardiology Division, Larner College of Medicine at the University of Vermont, Burlington, VT, 05405, USA
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Broeks IJ, Hermans DJ, Dassel AC, van der Vleuten CJ, van Beynum IM. Propranolol treatment in life-threatening airway hemangiomas: a case series and review of literature. Int J Pediatr Otorhinolaryngol 2013; 77:1791-800. [PMID: 24074695 DOI: 10.1016/j.ijporl.2013.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 08/05/2013] [Accepted: 08/09/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Infantile hemangiomas (IHs) in the airway may be potentially life-threatening during the proliferative phase. Available treatments like oral corticosteroids (OCS) and chemotherapeutic agents usually showed variable responses and serious side effects. Propranolol is a new and promising treatment option. METHODS A case series of five IH patients with airway involvement is presented, supplemented with a review of literature. Propranolol treatment (2.0-3.0mg/kg/day) was initiated between 3 weeks and 6 months of age. Three cases were treated with propranolol monotherapy, 2 cases with OCS primarily and propranolol secondarily, in which treatment with OCS could be reduced rapidly. RESULTS In our case series a dramatic, fast response was observed in all cases, with a permanent effect after discontinuation in four cases. In one patient a relapse of airway problems occurred two months after discontinuation of propranolol at 16 months of age; this resolved after re-start of propranolol. Review of literature together with these five cases showed 81 patients with airway IHs treated with propranolol. Propranolol was effective in 90% of the cases and seven patients were classified as non-responders. Eight IHs relapsed while weaning of propranolol or after discontinuation; dose adjustment or restart was effective in most cases but one patient appeared resistant to therapy. CONCLUSIONS Propranolol seems to be a rapidly effective and safe treatment strategy for most IHs obstructing the airway. Because of the fast and important effects of propranolol, randomized controlled trials are hardly justifiable for this specific, relatively rare but, acute treatment indication. Despite the efficacy of propranolol, close monitoring of the patients with an airway IH is required, considering the risk of relapse of symptoms during or after treatment and the reported resistance to propranolol in at least 9% of the published cases. The dose and duration of treatment should be high and long enough to prevent relapse. Further research should focus on the optimal treatment protocol; the actual percentage of non-responders and also the mechanism of resistance to propranolol is unknown and needs to be illuminated.
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