Do beta-blockers reduce negative intrusive thoughts and anxiety in cancer survivors? - An emulated trial

BACKGROUND

High rates of negative intrusive thoughts have been reported among cancer patients. Prevalent users of beta-blocker therapy have reported lower levels of cancer related intrusive thoughts than non-user. The aim of this study is to investigate if initiation of beta-blocker therapy reduces the prevalence and severity of intrusive thoughts (co-primary endpoints) and the prevalence of anxiety, depressed mood, and low quality of life (secondary endpoints) in cancer survivors.

METHODS

Data on patient-reported outcomes from three cohort studies of Swedish patients diagnosed with colon, prostate or rectal cancer were combined with data on beta-blocker prescriptions retrieved from the Swedish Prescribed Drug Register. Two randomized controlled trials were emulated. Trial 1 had follow-up 1 year after diagnosis, trial 2 had follow-up 2 years after diagnosis, baseline in both trials was 12 months before follow-up. Those who initiated beta-blocker therapy between baseline and follow-up was assigned Active group, those who did not was assigned Control group. All endpoints were analysed using Bayesian ordered logistic regression.

RESULTS

Trial 1 consisted of Active group, n = 59, and Control group, n = 3936. Trial 2 consisted of Active group, n = 87, and Control group, n = 3132. The majority of participants were men, 83% in trial 1 and 94% in trial 2. The prevalence and severity of intrusive thoughts were lower in the Active group in trial 1, but no significant differences between groups were found in either trial. The prevalence of depressed mood, worse quality of life and periods of anxiety were higher in the Active group in both trials with significant differences for quality of life in trial 1 and anxiety in trial 2.

CONCLUSIONS

The emulated trials demonstrated no evidence of a protective effect of beta-blocker therapy against intrusive thoughts. The Active group had reduced quality of life and elevated anxiety compared to the Control group.

TRIAL REGISTRATION

The three cohort studies were registered at isrctn.com/clinicaltrials.gov (ISRCTN06393679, NCT02530593 and NCT01477229).

Early Intravenous Beta-Blockade with Esmolol in Adults with Severe Traumatic Brain Injury (EBB-TBI): Protocol for a Phase 2a Intervention Design Study

Traumatic brain injury is a leading cause of death and disability worldwide. Interventions that mitigate secondary brain injury have the potential to improve outcomes for patients and reduce the impact on communities and society. Increased circulating catecholamines are associated with worse outcomes and there are supportive animal data and indications in human studies of benefit from beta-blockade after severe traumatic brain injury. Here, we present the protocol for a dose-finding study using esmolol in adults commenced within 24 h of severe traumatic brain injury. Esmolol has practical advantages and theoretical benefits as a neuroprotective agent in this setting, but these must be balanced against the known risk of secondary injury from hypotension. The aim of this study is to determine a dose schedule for esmolol, using the continual reassessment method, that combines a clinically significant reduction in heart rate as a surrogate for catecholamine drive with maintenance of cerebral perfusion pressure. The maximum tolerated dosing schedule for esmolol can then be tested for patient benefit in subsequent randomized controlled trials.Trial registration ISRCTN, ISRCTN11038397, registered retrospectively 07/01/2021 https://www.isrctn.com/ISRCTN11038397.

Beta-blocker therapy in heart failure with preserved ejection fraction (B-HFpEF): A systematic review and meta-analysis

INTRODUCTION

While beta-blockers are considered the cornerstone of treatment for heart failure with reduced ejection fraction, the same may not apply to patients with heart failure with preserved ejection fraction (HFpEF). To date, the benefit of beta-blockers remains uncertain, and there is no current consensus on their effectiveness. This study sought to evaluate the efficacy of beta-blockers on mortality and rehospitalization among patients with HFpEF.

METHODS

A systematic review and meta-analysis of randomized or observational cohort studies examined the efficacy of beta-blocker therapy in comparison with placebo, control, or standard medical care in patients with HFpEF, defined as left ventricular ejection fraction ≥50 %. The main endpoints were mortality (i.e., all-cause and cardiovascular), rehospitalization (i.e., all-cause and for heart failure) and a composite of the two.

RESULTS

Out of the 13,189 records initially identified, 16 full-text records met the inclusion criteria and were analyzed recruiting a total of 27,188 patients. The mean age range was 62-84 years old, predominantly female, with HFpEF in which 63.4 % of patients received a beta-blocker and 36.6 % did not. The pooled analysis of included cohort studies, of variable follow-up durations, showed a significant reduction in all-cause mortality by 19 % (odds ratio (OR) 0.81; 95 % confidence interval (CI): 0.65-0.99, p = 0.044) whereas rehospitalization for heart failure (OR 1.13; 95 % CI: 0.91-1.41, p = 0.27) or its composite with all-cause mortality (OR 1.01; 95 % CI: 0.78-1.32, p = 0.92) were similar between the beta-blocker and control groups.

CONCLUSION

This meta-analysis showed that beta-blocker therapy has the potential to reduce all-cause mortality in patients with HFpEF based on observational studies. Nevertheless, it did not affect rehospitalization for heart failure or its composite with all-cause mortality. Large scale randomized trials are needed to clarify this uncertainty.

Mental Health of School-Aged Children Treated with Propranolol or Atenolol for Infantile Hemangioma and Their Parents

BACKGROUND

Infants with infantile hemangioma (IH) have been effectively treated with propranolol or atenolol. Concerns were raised about the mental health of these children at school age, due to central nervous system effects of propranolol and visible nature of IH.

OBJECTIVE

This study aimed to compare the mental health at school age of children treated with propranolol to children treated with atenolol for IHs and their parents.

METHODS

This two-centered cross-sectional study included children aged ≥6 years and treated with either propranolol or atenolol for IH during infancy. Children's outcomes were performance-based affect recognition (Dutch version of the Developmental Neuropsychological Assessment-II [NEPSY-II-NL]), parent-reported emotional and behavioral functioning (Child Behavioral Checklist [CBCL]), and health-related quality of life (KIDSCREEN-27). Parents' outcome was parenting stress (Parenting Stress Questionnaire [OBVL]).

RESULTS

Data of 105 children (36 propranolol, 69 atenolol; 6.0-11.8 years) were analyzed. Mental health outcomes did not differ between both β-blocker groups. Although overall functioning was in line with norms, children presented specific problems concerning affect recognition, parent-reported attention, and social quality of life. Parents showed increased physical symptoms, depressive symptoms, and parent-child relationship problems.

CONCLUSION

No difference in mental health at school age was found between children treated with propranolol or atenolol for IH. Although few overall mental health problems were found, specific problems require follow-up. Follow-up of children should be directed toward affect recognition, attention, and social functioning in daily life. Problems reported by parents could be ameliorated by mental health support during and after their infant's β-blocker treatment.

Association between antihypertensive medicine use and risk of ovarian cancer in women aged 50 years and older

BACKGROUND

Epithelial ovarian cancer (EOC) has few modifiable risk factors. There is evidence that some antihypertensive medicines may have cancer preventive and/or therapeutic actions; therefore, we assessed the associations between use of different antihypertensive medicines and risk of specific EOC histotypes.

METHODS

Our nested case-control study of linked administrative health data included 6070 Australian women aged over 50 years diagnosed with EOC from 2004 to 2013, and 30,337 matched controls. We used multivariable conditional logistic regression to estimate odds ratios (ORs) and 95 % confidence intervals (CIs) for the association between ever use of each antihypertensive medicine group, including beta-adrenergic blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, diuretics, and alpha blockers, and the risk of EOC overall and separately for the serous, endometrioid, mucinous, clear cell and other histotypes.

RESULTS

We found that most antihypertensive medicines were not associated with risk of EOC. However, women who used calcium channel blockers had a reduced risk of serous EOC (OR= 0.89, 95 % CI:0.81,0.98) and use of combination thiazide and potassium-sparing diuretics was associated with an increased risk of endometroid EOC (OR= 2.09, 95 % CI:1.15,3.82).

CONCLUSION

Our results provide little support for a chemo-preventive role for most antihypertensives, however, the histotype-specific associations we found warrant further investigation.

Effect of concurrent beta-blocker use in patients receiving immune checkpoint inhibitors for advanced solid tumors

PURPOSE

Stress-induced adrenergic signaling can suppress the immune system. In animal models, pharmacological beta-blockade stimulates CD8 + T-cell activity and improves clinical activity of immune checkpoint blockade (ICB) in inhibiting tumor growth. Herein, we investigated the effect of BB on clinical outcomes of patients receiving ICB in advanced solid tumors.

METHODS

We retrospectively evaluated patients with solid tumors treated with ICB at our institution from January 1, 2011 to April 28, 2017. The primary clinical outcome was disease control. Secondary clinical outcomes were overall survival (OS), and duration of therapy (DoT). The primary predictor was use of BB. Association between disease control status and BB use was assessed in univariable and multivariable logistic regression. OS was calculated using hazard ratios of BB-recipient patients vs. BB non-recipient patients via Cox proportional hazards regression models. All tests were two-sided at a significance level of 0.05.

RESULTS

Of 339 identified patients receiving ICB, 109 (32%) also received BB. In covariate-adjusted analysis, odds of disease control were significantly higher among BB recipients compared to BB-non-recipients (2.79; [1.54-5.03]; P = 0.001). While we did not observe significant association of OS with the use of BB overall, significant association with better OS was observed for the urothelial carcinoma cohort (HR: 0.24; [0.09, 0.62]; P = 0.0031).

CONCLUSIONS

Concurrent use of BB may enhance the clinical activity of ICB and influence overall survival, particularly in patients with urothelial carcinoma. Our findings warrant further investigation to understand the interaction of beta adrenergic signaling and antitumor immune activity and explore a combination strategy.

Long-term neurocognitive functioning of children treated with propranolol or atenolol for infantile hemangioma

The purpose of this study was to compare long-term neurocognitive functioning (working memory, processing speed, and attention) between children who had been treated with either propranolol or atenolol for infantile hemangioma during infancy. All eligible children (n = 158) aged 6 years or older and treated with propranolol or atenolol as infants were invited to participate in this two-center cross-sectional study. The primary outcome was the Wechsler Intelligence Scale for Children-V Cognitive Proficiency Index (CPI), a measure of working memory, processing speed, and attention. Secondary outcomes were general intelligence, auditory, visuospatial, and narrative memory, as well as executive functioning and sleep. A total of 105 children, of whom 36 had been treated with propranolol (age 6.0-11.8 years, follow-up time 1.6-9.7 years, 19% male) and 69 had been treated with atenolol (age 6.9-9.7 years, follow-up time 4.5-8.4 years, 19% male), were analyzed. The CPI and other neurocognitive outcomes did not differ between the propranolol and atenolol groups and were in line with general population test norms. Post hoc analyses revealed lower CPI scores for males, both compared to participating females (10.3 IQ points, medium effect size) and compared to matched test norms (12.4 IQ points, medium effect size).

CONCLUSIONS

 Long-term neurocognitive functioning did not differ between children treated with propranolol and those treated with atenolol for IH. Overall, propranolol and atenolol appear to be safe treatments for IH regarding long-term neurocognitive functioning. The substantially lower CPI scores in males warrant further investigation.

TRIAL REGISTRATION

 Netherlands Trial Register, NL7703 https://www.trialregister.nl/trial/7703 What is Known: • Infants with infantile hemangioma are effectively treated with propranolol or atenolol. • Parents and professionals are concerned about long-term neurocognitive effects.

WHAT IS NEW

• No long-term (≥ 6 years) differences in neurocognitive functioning were found between children treated with propranolol or atenolol. • Males treated with beta-blockers had substantially lower IQ scores than treated females and males from the general population, which is a matter of concern and should be considered when evaluating the risk/benefit ratio in less severe forms of infantile hemangioma.

The Role of Systemic and Topical Beta-Blockers in Dermatology: A Systematic Review

INTRODUCTION

Beta-blockers are proven to be safe and cost-effective agents in treating multiple dermatological conditions, which is why they are considered as an interesting and good alternative therapeutic agent by dermatologists. To our knowledge, there has been no comprehensive systematic review to date summarizing the role of both systemic and topical beta-blockers in dermatology.

METHODS

In this systematic review, we aim to review recent and relevant published literature in order to provide a comprehensive evidence-based summary to inform dermatologists.

RESULTS

An electronic-based literature search was carried out during October-December 2021 in the databases PubMed (MEDLINE), SCOPUS (EMBASE), and Cochrane Library. Furthermore, bibliographic sources were also reviewed for the selected articles. We followed The Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 (PRISMA) guidelines. We reviewed published literature about the role of beta-blockers in dermatology for the time period (January 2016 to December 2021).

CONCLUSIONS

A total of 126 publications were retrieved from different databases, of which 59 studies were finally included in our review after excluding non-eligible literature in accordance with our inclusion and exclusion criteria. The included articles consisted of meta-analyses, systematic reviews, clinical trials, retrospective and prospective cohort studies, case-control studies, case series, and case reports. In general, data in reviewed literature showed that both systemic and topical beta-blockers were reliable and safe therapeutic options in treating different dermatoses. Their effect has been studied as a mono-therapy, also as an adjuvant therapy combined with other current disease-specific therapeutic modalities such as lasers, radiation, chemotherapy, corticosteroids, or other beta-blockers options. Local and systemic adverse effects were mainly minor and non-significant.

Prognostic and predictive value of β-blockers in the EORTC 1325/KEYNOTE-054 phase III trial of pembrolizumab versus placebo in resected high-risk stage III melanoma

BACKGROUND

β-adrenergic receptors are upregulated in melanoma cells and contribute to an immunosuppressive, pro-tumorigenic microenvironment. This study investigated the prognostic and predictive value of β-adrenoreceptor blockade by β-blockers in the EORTC1325/KEYNOTE-054 randomised controlled trial.

METHODS

Patients with resected stage IIIA, IIIB or IIIC melanoma and regional lymphadenectomy received 200 mg of adjuvant pembrolizumab (n = 514) or placebo (n = 505) every three weeks for one year or until recurrence or unacceptable toxicity. At a median follow-up of 3 years, pembrolizumab prolonged recurrence-free survival (RFS) compared to placebo (hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.47-0.68). β-blocker use was defined as oral administration of any β-blocker within 30 days of randomisation. A multivariable Cox proportional hazard model was used to estimate the HR for the association between the use of β-blockers and RFS.

RESULTS

Ninety-nine (10%) of 1019 randomised patients used β-blockers at baseline. β-blockers had no independent prognostic effect on RFS: HR 0.96 (95% CI 0.70-1.31). The HRs of RFS associated with β-blocker use were 0.67 (95% CI 0.38-1.19) in the pembrolizumab arm and 1.15 (95% CI 0.80-1.66) in the placebo arm. The HR of RFS associated with pembrolizumab compared to placebo was 0.34 (95% CI 0.18-0.65) among β-blocker users and 0.59 (95% CI 0.48-0.71) among those not using β-blockers.

CONCLUSIONS

This study suggests no prognostic effect of β-blockers in resected high-risk stage III melanoma. However, β-blockers may predict improved efficacy of adjuvant pembrolizumab treatment. The combination of immunotherapy with β-blockers merits further investigation. This study is registered with ClinicalTrials.gov, NCT02362594, and EudraCT, 2014-004944-37.

[Heart rate control in shock]

Heart rate is well established in the diagnosis of shock; however, the mechanisms regulating heart rate, systemic resistance and blood pressure remain unclear. The concept of heart rate control in shock-related tachycardia has been known for about 50 years. Elevated heart rates in septic shock have been identified as an indicator of increasingly inefficient hemodynamics, worsening perfusion and organ function as well as of an unfavourable prognosis. Many drugs used for heart rate control also lower blood pressure. The challenge of this therapeutic concept is achieving optimal heart rate control without provoking critical hypotension. Only in recent years has the development of highly cardioselective, short- and ultrashort-acting β‑blockers such as esmolol and landiolol made it possible to prove the feasibility and usefulness of heart rate control in certain types of shock.

In at-risk patients without CVD, polypill plus aspirin reduced a composite of major CV events at 4.6 y

Yusuf S, Joseph P, Dans A, et al. Polypill with or without aspirin in persons without cardiovascular disease. N Engl J Med. 2021;384:216-28. 33186492.

Effect of comorbid migraine on propranolol efficacy for painful TMD in a randomized controlled trial

Introduction

The migraine-preventive drug propranolol is efficacious in reducing pain from temporomandibular disorder, suggesting potential modifying or mediating effects of comorbid migraine.

Methods

In this randomized controlled trial, myofascial temporomandibular disorder patients were treated with propranolol or placebo for 9 weeks. The primary endpoint was change in a facial pain index derived from daily symptom diaries. Linear and logistic regression models tested for a migraine × treatment-group interaction in reducing facial pain index. Counterfactual models explored changes in headache impact and heart rate as mediators of propranolol's efficacy.

Results

Propranolol's efficacy in reducing facial pain index was greater among the 104 migraineurs than the 95 non-migraineurs: For example, for the binary ≥ 30% reduction in facial pain index, odds ratios were 3.3 (95% confidence limits: 1.4, 8.1) versus 1.3 (0.5, 3.2), respectively, although the interaction was statistically non-significant (p = 0.139). Cumulative response curves confirmed greater efficacy for migraineurs than non-migraineurs (differences in area under the curve 26% and 6%, respectively; p = 0.081). While 9% of the treatment effect was mediated by reduced headache impact, 46% was mediated by reduced heart rate.

Conclusions

Propranolol was more efficacious in reducing temporomandibular disorder pain among migraineurs than non-migraineurs, with more of the effect mediated by reduced heart rate than by reduced headache impact.

Study identification and registration

SOPPRANO; NCT02437383; https://clinicaltrials.gov/ct2/show/NCT02437383

Pharmacological treatment and inappropriate prescriptions for patients with erectile dysfunction

Background Erectile dysfunction is associated with old age, some morbidities and the use of certain medications. Objective To identify the treatments and drugs related to worsening sexual activity in patients with erectile dysfunction. Setting Patients diagnosed with erectile dysfunction during 2018. Methods This cross-sectional study of a population database identified all drug prescriptions of patients with erectile dysfunction during 2018. Main outcome measure The identification of other comorbidities and potentially inappropriate drugs that could worsen erectile dysfunction. Results A total of 2999 patients with erectile dysfunction (mean age 59.6 ± 12.1 years) were identified. A total of 88.2% received pharmacological treatment for erectile dysfunction, mainly tadalafil (70.5%). A total of 47.6% of all patients received at least one medication associated with worsening erectile dysfunction, especially hydrochlorothiazide (17.0%), metoprolol (7.9%) and sertraline (6.7%). Residing in Cali (OR 1.86; 95% CI 1.52-22.27) or Bucaramanga (OR 2.23; 95% CI 1.39-33.58), having 3 or more chronic comorbidities (OR 1.52; 95% CI 1.04-2.24) and presenting psychiatric (OR 5.5; 95% CI 3.70-8.17), cardiovascular (OR 3.48; 95% CI 2.79-4.33), genitourinary (OR 1.31; 95% CI 1.05-1.64) pathologies or chronic kidney failure (OR 1.84; 95% CI 1.18-2.21) elevated the probability of receiving these prescriptions. Conclusions The pharmacological treatment of erectile dysfunction was in accordance with the recommendations of clinical practice guidelines, but the high proportion of potentially inappropriate prescriptions makes it necessary to promote educational and pharmacovigilance strategies that improve the prescription habits of physicians involved in caring for this group of patients.

QT interval abnormalities and heart rate variability in patients with cirrhosis

BACKGROUND AND STUDY AIMS

We aimed to assess the relationship of the QT interval and heart rate variability with the severity and aetiology of cirrhosis and determine the effect of propranolol on them.

PATIENTS AND METHODS

This prospective study included 44 patients with cirrhosis categorised into three groups based on the Child-Pugh score: groups 1, 2 and 3 (with 12, 15 and 15 patients, respectively). Demographic characteristics, propranolol administration, severity of cirrhosis evaluated by the Child-Pugh score, aetiology of cirrhosis, and serum sodium, potassium and calcium levels were evaluated. All patients underwent 24 h-Holter monitoring. Corrected QT interval (QTc), average heart rate, standard deviation of normal-to-normal intervals (SDNN) and corrected SDNN (cSDNN) were evaluated.

RESULTS

The average QTc was significantly longer in group 3 than in groups 1 and 2 (453.4 ± 17.4 vs 422.8 ± 18.6 and 428.9 ± 17.24 ms, p < 0.001). The median SDNN was 70 ms and was significantly lower in group 3 vs groups 1 and 2 (77; interquartile range [IQR], 67-89.5 vs 57; IQR, 38-68 and 75 ms; IQR, 61-81 ms, p = 0.003). cSDNN was significantly lower in group 3 vs groups 1 and 2 (200.0 ± 42.6 vs 254.5 ± 75.3 and 277.8 ± 110.6 ms, p = 0.022). Propranolol administration resulted in a significant increase in the average SDNN value but had no effect on cSDNN or QTc. QTc was associated with the Child-Pugh class (p < 0.001), viral aetiology (p = 0.009) and sex (p = 0.010); SDNN was associated with the mean heart rate (p = 0.015) and Child-Pugh class (p = 0.024).

CONCLUSION

QTc interval prolongation and decreased SDNN are common in cirrhosis. Their prevalence is closely associated with disease severity. Propranolol has no effects on cSDNN or QTc.

Efficacy and safety of adrenergic beta-antagonist combined with lasers in the treatment of infantile hemangiomas: a meta-analysis

To investigate the efficacy and safety of combined therapy with adrenergic beta-antagonist and lasers in infantile hemangiomas (IH). A search of Pubmed, Cochrane, Embase, Wanfang Date, CNKI (China National Knowledge Infrastructure) and CBM (China Biology Medicine) databases was conducted to identify studies that examined response to combined therapy with adrenergic beta-antagonist and laser in IH patients. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) in random-effects or fixed-effects models were calculated with Review Manger 5.3. Efficacy of combined therapy with oral propranolol and lasers was significantly better than that of propranolol (OR 5.79, 95% CI 2.52-13.31, P < 0.00001) or lasers (OR 5.09, 95% CI 3.04-8.54, P < 0.00001) alone. Combined therapy with topical timolol and lasers was more effective than topical timolol (OR 3.71, 95% CI 2.46-5.59, P < 0.00001) or lasers (OR 10.92, 95% CI 1.90-62.70, P = 0.007) alone. We did not observe statistically significant differences of adverse reactions between combined therapy with oral propranolol and lasers and propranolol (OR 1.09, 95% CI 0.64-1.84, P = 0.75) or lasers (OR 0.83, 95% CI 0.28-2.50, P = 0.74). The incidence of adverse reactions in combined therapy with topical timolol and lasers and monotherapy with topical timolol therapy (OR 0.50, 95% CI 0.14-1.80, P = 0.75) or lasers (OR 0.29, 95% CI 0.06-1.55, P = 0.15) has no significant difference. The average treatment duration of combined therapy may be shorter than that of monotherapy. Combination therapy of adrenergic beta-antagonist and lasers on IH is significantly more effective than monotherapy, while the safety of combination therapy was not significantly higher than that of monotherapy.

Pulse Oximeter Plethysmograph Variation During Hemorrhage in Beta-Blocker-Treated Swine

BACKGROUND

Beta-blockers blunt the stress response to hemorrhage. Our aim was to investigate the feasibility of noninvasive pulse oximeter plethysmographic waveform variation (PoPV) for predicting blood volume loss in an esmolol-treated swine hemorrhagic shock model.

MATERIALS AND METHODS

Controlled hemorrhage was induced in eight male domestic pigs. In four pigs, a total of 15% and 30% blood volume was drawn step-by-step over 10 min in each step (controlled hemorrhage-only pigs). In the other four pigs, the heart rate (HR) was reduced and maintained by 30% from baseline by esmolol infusion before controlled hemorrhage (esmolol-treated pigs). Diagnostic abilities of HR, pulse pressure variation (PPV), PoPV, and mean arterial pressure for 15% and 30% blood volume loss were determined by the area under the receiver operating characteristic curve (AUC).

RESULTS

PoPV was well correlated with PPV in controlled hemorrhage-only pigs (r = 0.717) and esmolol-treated pigs (r = 0.532). In controlled hemorrhage-only pigs, HR (AUC = 0.841 and 0.864), PPV (0.878 and 0.843), and PoPV (0.779 and 0.793) accurately predicted 15% and 30% of blood volume loss. In esmolol-treated pigs, the diagnostic ability of HR was decreased (AUC = 0.766 and 0.733). However, diagnostic abilities of PPV (0.848 and 0.804) and PoPV (0.808 and 0.842) were not deteriorated.

CONCLUSIONS

The diagnostic ability of HR for blood volume loss was blunted by esmolol. However, those of PPV and PoPV were not altered. PoPV may be considered to be a useful noninvasive tool to predict blood volume loss in injured patients taking beta-blockers.

Evaluation of the effects of β1-selective beta-blockers on bone mineral density and fracture risk in postmenopausal women

Background/aim

β1-selective beta-blockers (BBs) are sympatholytic agents, and discerning their effects on bone health would be of great importance. This study aimed to investigate the influence of β1-selective BBs on bone mineral density (BMD) and fracture risk.

Materials and methods

This study included postmenopausal women who used β1-selective BBs (BB group) and control group. Sociodemographic characteristics, BMD and previous fragility fractures were recorded. Additionally, the 10-year probability of a major osteoporotic and hip fracture was calculated using the fracture risk assessment tool (FRAX).

Results

A total of 60 participants were included in the study. L1-4 and L2-4 BMD values were significantly higher in BB group than control group (P = 0.015 and P = 0.025, respectively). Moreover, T-scores of lumbar and femur total were significantly higher in the BB group. Two patients in BB and 6 patients in control group had previous fragility fracture. No statistically significant intergroup difference was noted regarding FRAX.

Conclusion

Based on our results, β1-selective BB usage was associated with higher BMD at the lumbar region in postmenopausal women.

Beta-Blockade in Aneurysmal Subarachnoid Hemorrhage: a Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVE

Sympathetic nervous system activation after aneurysmal subarachnoid hemorrhage (aSAH) is associated with complications and poor outcome. In this systematic review and meta-analysis, we investigate the effect of beta-blockers on outcome after aSAH.

METHODS

The review was prospectively registered with PROSPERO (CRD42019111784). We performed a systematic literature search of MEDLINE, EMBASE, the Cochrane Library, published conference proceedings, and abstracts. Eligible studies included both randomized controlled trials and observational studies up to October 2018, reporting the effect of beta-blocker therapy on the following outcomes in aSAH: mortality, vasospasm, delayed cerebral ischemia, infarction or stroke, cardiac dysfunction, and functional outcomes. Studies involving traumatic SAH were excluded. Citations were reviewed, and data extracted independently by two investigators using a standardized proforma.

RESULTS

We identified 819 records with 16 studies (four were randomized controlled trials) including 6702 patients selected for analysis. Exposure to beta-blockade either before or after aSAH was associated with a significant reduction in unadjusted mortality (RR 0.63, 95% CI 0.42-0.93, p = 0.02). A significant reduction in unadjusted mortality was also seen in prospective trials of post-event beta-blockade (RR 0.51, 95% CI 0.28-0.93, p = 0.03). Statistically significant differences were not seen for other outcomes investigated.

CONCLUSIONS

In adult patients with aSAH, beta-blocker therapy is associated with a mortality benefit. Studies are generally of a low quality with considerable clinical heterogeneity. Prospective large interventional trials with patient centered outcomes are required to validate this finding.

Impact of Angiotensin Receptor Blockers, Beta Blockers, Calcium Channel Blockers and Thiazide Diuretics on Survival of Ovarian Cancer Patients

Purpose

We investigated the impact of four types of antihypertensive medications, angiotensin receptor blockers (ARBs), beta blockers (BBs; both selective and non-selective), calcium channel blockers (CCBs), and thiazide diuretics (TDs) on survival outcomes in epithelial ovarian cancer (EOC).

Materials and Methods

A single-institutional retrospective chart review of 878 patients with EOC was performed. Survival was compared according to use of the four antihypertensive medications during primary treatment. Propensity score matching (ratio 1:3) was performed to control possible associated covariates, such as age, International Federation of Gynecology and Obstetrics stage, residual status after primary debulking surgery, and co-morbidity.

Results

Among 878 patients, 56 patients (6.4%) were ARB users, 62 (7.1%) were BB users, 107 (12.2%) were CCBs users and 32 (3.6%) used TDs. Median progression-free survival (PFS) for ARB, BB, and CCB users was 37.8, 27.2, and 23.6 months compared with 33.6 months for non-users. ARB was associated with 35% decreased risk of disease progression (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.42 to 0.99; p=0.046) in multivariate analysis. After propensity score matching, median PFS for ARB users was 37.8 months and ARB use remained to be associated with lower recurrence rate in univariate (p=0.035) and multivariate analysis (HR, 0.60; 95% CI, 0.39 to 0.93; p=0.022).

Conclusion

In this study, ARBs use during primary treatment is associated with lower recurrence in EOC patients. However, CCBs, BBs, and TDs did not show beneficial impact.

Clinical Impact of Beta Blockers in Patients with Myocardial Infarction from the Korean National Health Insurance Database

BACKGROUND AND OBJECTIVES

Whether beta blockers favorably impact the clinical outcome in patients with acute myocardial infarction (AMI) remains in debate. We investigated the impact of beta blocker on major clinical outcomes during 2 years after percutaneous coronary intervention (PCI) in patients with AMI.

METHODS

All patients with the first AMI treated with PCI for the period of 2005 to 2014 from the Korean National Health Insurance Service claims database were enrolled. We defined the regular user as medication possession ratio (MPR) ≥80% and non-user as MPR=0%. We compared the occurrence of all cause death, myocardial infarction (MI) and stroke according to adherence of beta-blockers. A 1:1 propensity score-matching was conducted to adjust for between-group differences.

RESULTS

We identified a total 81,752 patients with met eligible criteria. At discharge, 63,885 (78%) patients were prescribed beta blockers. For 2 years follow up period, regular users were 53,991 (66%) patients, non-users were 10,991 (13%). In the propensity score matched population, regular use of beta blocker was associated with a 36% reduced risk of composite adverse events (all death, MI or stroke) (hazard ratio [HR], 0.636; 95% confidence interval [CI], 0.555-0.728; p<0.001). Compared to no use of beta blocker, regular use significantly reduced all death (HR, 0.736; 95% CI, 0.668-0.812; p<0.001), MI (HR, 0.729; 95% CI, 0.611-0.803; p<0.001) and stroke (HR, 0.717; 95% CI, 0.650-0.791; p<0.001).

CONCLUSIONS

Prescription of beta blocker in patients with AMI after PCI was sequentially increased. Continuous regular use of beta blocker for 2 years after AMI reduced major adverse events compared to no use of beta blocker.

[Drug treatment of heart failure in chronic kidney disease]

Patients with chronic kidney disease (CKD) exhibit an increased risk to develop heart failure and the presence of heart failure in CKD patients is associated with a poorer prognosis. The following overview article summarizes the current standard of drug treatment of heart failure and discusses special aspects in the treatment of patients with CKD.

Liver volume index predicts the risk of esophageal variceal hemorrhage in cirrhotic patients on propranolol prophylaxis

BACKGROUND/AIMS

Non-selective β-blockers (NSBBs) are used for primary prevention of esophageal variceal hemorrhage (VH) in patients with portal hypertension, but a significant number of patients develop VH while on NSBB therapy. In this study, we sought to determine whether liver volume can predict the risk of primary prophylaxis failure in cirrhotic patients on NSBB therapy.

METHODS

A retrospective cohort of 309 patients on prophylactic propranolol was analyzed. Liver volume was measured in portal venous phase images of multidetector computed tomography. Predictors of VH were assessed using a Cox proportional hazards model with competing-risks analysis. A nomogram was developed for estimation of the risk of primary prophylaxis failure.

RESULTS

During a median follow-up of 36 months, 37 patients on propranolol developed VH. Liver volume index, the ratio of measured-to-expected liver volume, was an independent predictor of VH (adjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.37 to 5.33; p = 0.004) as were the presence of large varices and the absence of ascites. A nomogram-based volume score of > 0.6 was predictive of prophylaxis failure (HR, 7.54; 95% CI, 2.88 to 19.73; p < 0.001). Time-dependent receiver operating characteristic curve analysis revealed that a nomogram-based risk score had significantly better discriminatory power than the North Italian Endoscopy Club index in predicting prophylaxis failure at 6 and 8 years.

CONCLUSION

Liver volume index is an independent predictor of first VH and a nomogram-based volume score stratifies the VH risk in cirrhotic patients on propranolol prophylaxis.

Patient-Important Adverse Events of β-blockers in Frail Older Adults after Acute Myocardial Infarction

BACKGROUND

We evaluated the burden of adverse events caused by β-blocker use after acute myocardial infarction (AMI) in frail, older nursing home (NH) residents.

METHODS

This retrospective cohort study used national Medicare claims linked to Minimum Data Set assessments. The study population was individuals aged ≥65 years who resided in a U.S. NH for ≥30 days, had a hospitalized AMI between May 2007 and March 2010, and returned to the NH. Exposure was new use of β-blockers versus nonuse post-AMI. Orthostasis, general hypotension, falls, dizziness, syncope, and breathlessness outcomes were measured over 90 days of follow-up. Odds ratios (ORs) with 95% confidence intervals (CIs) for outcomes were estimated using multinomial logistic regression models after 1:1 propensity score-matching of β-blocker users to nonusers.

RESULTS

Among the 10,992 NH propensity score-matched residents with an AMI, the mean age was 84 years and 70.9% were female. β-blocker users were more likely than nonusers to be hospitalized for hypotension (OR = 1.20, 95% CI 1.03-1.39) or experience breathlessness (OR = 1.10, 95% CI 1.01-1.20) after AMI. With the exception of falls, other outcome estimates, though imprecise, were compatible with a potential elevated risk of orthostasis (OR = 1.14, 95% CI 0.96-1.35), syncope, (OR = 1.24, 95% CI 0.55-2.77), and dizziness (OR = 1.28, 95% CI 0.82-1.99) among β-blocker users.

CONCLUSIONS

Considered alongside prior evidence that β-blockers may worsen functional outcomes in NH residents with poor baseline functional and cognitive status, our results suggest that providers should exercise caution when prescribing for these vulnerable groups, balancing the mortality benefit against the potential for causing adverse events.

Esmolol indirectly stimulates vagal nerve activity in endotoxemic pigs

Background

There is an increasing interest in beta-blockade as a therapeutic approach to sepsis following consistent experimental findings of attenuation of inflammation and improved survival with beta1 selective antagonist. However, the mechanism of these beneficial effects remains very uncertain. Thus, this study is aimed at investigating the effects of a beta-1 selective blockade on sympathetic/parasympathetic activity in endotoxin-challenged pigs using heart rate variability. The hypothesis is that an adrenergic blockade could promote parasympathetic activity. Indeed, the increase of parasympathetic activity is a mechanism recently described as beneficial in septic states.

Methods

Fifty-one endotoxin-challenged pigs were studied. After 30 min of endotoxin infusion and 30 min of evolution without intervention, the pigs were randomly assigned the placebo or esmolol treatment and were observed for 200 min. Overall heart rate variability was assessed continuously, in the temporal domain by standard deviation of RR intervals (SDNN, ms),and in the frequency domain by spectral powers of low frequency (LF, ms² × 10³/Hz) and high frequency (HF, ms² × 10³/Hz) bands.

Results

Variations of power in these frequency bands were interpreted as putative markers of sympathetic (LF) and parasympathetic (HF) activity. In LPS treated animals, Esmolol did not increase SDNN, but instead decreased LF and increased HF power.

Conclusion

These spectral modifications associated to a beta-blocker treatment after an endotoxemic challenge are interpreted as a significant decrease of sympathetic activity and an indirect increase of vagal autonomic tone.

Electronic supplementary material

The online version of this article (10.1186/s40635-018-0178-1) contains supplementary material, which is available to authorized users.

[Pharmacokinetic risk factors of beta-blockers overdose in the elderly: Case report and pharmacology approach]

Beta-blockers are widely prescribed in elderly patients and may induce severe adverse drug reactions. We report a case of bisoprolol-induced bradycardia in an elderly patient with impaired renal function and use of cytochrome P450 inhibitors. A literature review has been performed in order to analyze pharmacokinetic risk factors of beta-blockers overdosing in geriatrics. Various mechanisms can result in decreased elimination of beta-blockers. These mechanisms vary according to the beta-blocker agent and may be combined in some individuals, especially elderly patients. This can lead to unexpected overexposure. Knowledge about drug interactions and pharmacokinetic elimination pathways is important for preventing overexposure and adverse drug reactions when using beta-blockers.

[Heart rate control in chronic heart failure patients received cardiovascular implantable electronic device therapy: effects of optimized medication]

Objective: To investigate the heart rate control situation of chronic heart failure (CHF) patients who received cardiovascular implantable electronic device (CIED) therapy, and to assess the heart rate control efficacy by optimized medication adjustment. Methods: We performed a perspective study in heart failure with reduced left ventricular ejection fraction (HFrEF) patients who received CIED according to guideline recommendations, patients were enrolled from January 2012 to January 2017. Resting heart rate (RHR) recorded by electrocardiogram after 10 minutes' rest and medication usage within 1 month were recorded at baseline. RHR less than 70 beats per minute (bpm) was regarded as well controlled. β-receptor blockers and (or) ivabradine would be added in patients whose RHR were over 70 bpm. RHR after optimized medication adjustment was recorded during follow-up period. Results: One hundred and fifty patients were included in this study with average RHR (80.6±11.9) bpm. RHR was<70 bpm in 27.3% (41/150) patients at baseline and β-receptor blockers was underused in 80.7% patients (88/109) whose RHR was>70 bpm. The overall RHR decreased to (73.1±10.4) bpm and percent of patients with RHR<70 bpm increased to 70.0% (105/150) after up-titration of β-receptor blockers compared to baseline (χ²=52.958, P<0.001). Ivabradine was added in the rest 45 patients and RHR was<70 bpm in 43 out of 45 patients after ivabradine use. The overall RHR decreased to (67.1±2.7) bpm and percent of RHR<70 bpm significantly increased to 98.7% (148/150) (χ²=44.504, P<0.001 vs. up-titration of β-receptor blockers only). Conclusion: RHR in CHF patients who received CIED therapy is not ideally controlled in this patient cohort, individual up-titration ofβ-receptor blockers and ivabradine use may help to optimize RHR in these patients.

Pharmacological intervention in hypertension using beta-blockers: Real-world evidence for long-term effectiveness

The study objective was to compare the long-term incidence and risk of mortality and cardiovascular outcomes in patients with hypertension initiating bisoprolol, other β-blockers or other antihypertensive therapies. Cohort analysis using UK Clinical Practice Research Datalink (CPRD). Adult patients with first diagnosis of hypertension recorded between 2000 and 2014, with ≥365 days of registration to first event and initiating monotherapies of bisoprolol, other β-blockers or drugs other than β-blockers within 6 months of diagnosis were included. Incidence rates (IR) for each treatment cohort were compared using adjusted hazard ratio (HR) and 95% confidence intervals (CI) obtained from Cox regression analyses. Of 100,066 patients included, 539 were prescribed bisoprolol, 3701 other β-blockers, and 95,826 drugs other than β-blockers. Patients receiving bisoprolol had significantly increased survival from 2 up to <15 years (HR for <15 years 0.34; 95% CI 0.18-0.67) versus other β-blockers, and from 5 to <15 years (HR for <15 years 0.52; 95% CI 0.27-1.00) versus drugs other than β-blockers. Over time, the risk of arrhythmia was higher in the bisoprolol cohort versus other β-blockers, and risks of arrhythmia and angina were higher versus drugs other than β-blockers. No differences in the risk of embolism, stroke, and myocardial infarction (MI) were found between cohorts. Over time, mortality and cardiovascular outcome IRs decreased in each cohort. In conclusion, bisoprolol showed sustained benefit on survival, evident from 2 years after treatment initiation versus other β-blockers, and from 5 years versus drugs other than β-blockers, providing long-term evidence supporting the use of bisoprolol in patients with hypertension in primary care.

Hypertension and Male Fertility

As the age of paternity rises in the developed world, issues of chronic disease may affect prospective fathers. Given the high prevalence of hypertension, researchers have begun to explore the relationship between hypertensive disease and male fertility. The current literature suggests an association between hypertension and semen quality. The use of various antihypertensive medications has also been linked to impaired semen parameters, making it difficult to discern whether the association exists with hypertension or its treatment. Further investigation is warranted to determine whether the observed associations are causal.

Prognosis of heart failure with preserved ejection fraction treated with β-blockers: A propensity matched study in the community

BACKGROUND

The effect of treatment with β-blockers on the prognosis of patients newly diagnosed with heart failure with preserved ejection fraction (HFpEF) is unknown.

OBJECTIVE

To analyze the relationship of commencing treatment with the β-blockers bisoprolol or carvedilol (CT-βB) with the prognosis of newly diagnosed HFpEF.

METHODS

Prospective study over 10years on 2704 patients with HFpEF. Main outcomes were mortality (all-cause and cardiovascular), hospitalizations for HF worsening, and visits. The independent relationship between CT-βB and the prognosis, stratifying patients for cardiovascular co-morbidity after propensity score-matching (985 patients CT-βB vs. another 985 patients non-CT-βB), was analyzed.

RESULTS

During a median follow-up of 1877.4days (interquartile range, 1-3651.2) 1600 died (81.2%), and 1702 were hospitalized (86.4%). CT-βB was associated with a lower risk of mortality (all-cause: HR [CI 95%] 0.78 [0.71 to 0.85], and cardiovascular: 0.75 [0.69 to 0.82]), a lower hospitalization rate (per 100 persons-year), 15.8 vs. 19.2, and a lower 30-day readmission rate (per 100 persons-year), 4.0 vs. 5.8, (P<0.001 in all cases), even after adjustment for the propensity to take β-blockers or other medications, comorbidities, and other potential confounders. These effects of CT-βB were independent of gender, and were observed in both patients taking high dose βB (over the median dose) and lower dose βB (under or equal to the median dose).

CONCLUSIONS

In this propensity matched study, commencing treatment with bisoprolol or carvedilol, both at high and at lower doses, is associated with an improved prognosis of patients newly diagnosed with HFpEF.

[Results of an intervention to reduce potentially inappropriate prescriptions of beta blockers and calcium channel blockers]

OBJECTIVE

To determine the frequency of simultaneous prescription of β-blockers and calcium channel blockers, notify the cardiovascular risk of these patients to the health care professionals in charge of them, and achieve a reduction in the number of those who use them.

METHODS

Quasi-experimental, prospective study by developing an intervention on medical prescriptions of patients older than 65 years treated between January 1 and July 30, 2014, affiliated to the Health System in 101 cities in Colombia. A total of 43,180 patients received a β-blocker each month, and 14,560 receiving a calcium channel blocker were identified. Educational interventions were performed and an evaluation was made, using sociodemographic and pharmacological variables, on the number of patients that stopped taking any of the two drugs in the following three months.

RESULTS

A total of 535 patients, with a mean age 75.8±6.7 years received concomitant β-blockers plus calcium channel blockers. Modification of therapy was achieved in 235 patients (43.9% of users) after 66 educational interventions. In 209 cases (88.9%) one of the two drugs was suspended, and 11.1% changed to other antihypertensive drugs. The variable of being more than 85 years old (OR: 1.93; 95% CI: 1.07-3.50), and receiving concomitant medication with inhibitors of the renin-angiotensin system (OR: 2.16; 95% CI: 1.28-3.65) were associated with increased risk of their doctor changing or stopping the prescription.

CONCLUSIONS

An improved adherence to recommendations for appropriate use of β-blockers and calcium channel blockers by health service providers was achieved. Intervention programs that reduce potentially inappropriate prescriptions for patients treated for cardiovascular disease should be used more frequently.

Endothelin 1 and transforming growth factor-β1 correlate with liver function and portal pressure in cirrhotic patients

OBJECTIVE

The invasive measurement of hepatic venous pressure gradient is the recommended method for the assessment of portal hypertension. We assessed if the mediators that regulate portal hypertension may be used as noninvasive markers of portal hypertension and liver insufficiency.

MATERIALS AND METHODS

We explored in prospective, observational study the concentration of endothelin-1, nitric oxide, and transforming growth factor-β1/2 in peripheral and hepatic venous blood; their relationship with the values of portal hypertension and liver insufficiency; and their level changes 4-6 months after non-selective beta-blocker therapy in cirrhotic patients with non-bleeding esophageal varices.

RESULTS

(1) Cirrhotics have significantly increased peripheral endothelin 1 and decreased transforming growth factor-β1 levels; (2) peripheral levels of all factors correlated significantly with their hepatic levels; (3) after therapy, peripheral endothelin-1 levels significantly increased, but transforming growth factor-β2 levels decreased and were lower in patients with pressure gradient value normalization; (4) before and after therapy, peripheral and hepatic endothelin-1, transforming growth factor-β1/2 levels correlated significantly with liver failure indicators (laboratory parameters, Child-Pough and MELD scores) and pressure gradient values.

CONCLUSIONS

Peripheral endothelin-1 and transforming growth factor-β1 levels, which strongly correlate with their hepatic levels, reflect the stage of portal hypertension and liver insufficiency in cirrhosis.

Economic benefits associated with beta blocker persistence in the treatment of hypertension: a retrospective database analysis

OBJECTIVES

To assess the association between medical costs and persistence with beta blockers among hypertensive patients, and to quantify persistence related medical cost differences with nebivolol, which is associated with improved tolerability, versus other beta blockers.

METHODS

Adults who initiated hypertension treatment with a beta blocker were identified from the MarketScan * claims database (2008-2012). Patients were classified based on their first beta blocker use: nebivolol, atenolol, carvedilol, metoprolol, and other beta blockers. Patients with compelling indications for atenolol, carvedilol or metoprolol (acute coronary syndrome and congestive heart failure) were excluded. Patients enrolled in health maintenance organization or capitated point of service insurance plans were also excluded. Persistence was defined as continuous use of the index drug (<60 day gap). The average effect of persistence on medical costs (2012 USD) was estimated using generalized linear models (GLMs). Regression estimates were used to predict medical cost differences associated with persistence between nebivolol and the other cohorts.

RESULTS

A total of 587,424 hypertensive patients met the inclusion criteria. Each additional month of persistence with any one beta blocker was associated with $152.51 in all-cause medical cost savings; continuous treatment for 1 year was associated with $1585.98 in all-cause medical cost savings. Patients treated with nebivolol had longer persistence during the 1 year study period (median: 315 days) than all other beta blockers (median: 156-292 days). Longer persistence with nebivolol translated into $305.74 all-cause medical cost savings relative to all other beta blockers.

LIMITATIONS

The results may not be generalizable to hypertensive patients with acute coronary syndrome or congestive heart failure.

CONCLUSIONS

Longer persistence with beta blockers for the treatment of hypertension was associated with lower medical costs. There may be greater cost savings due to better persistence with nebivolol than other beta blockers.

Management of anesthesia in unspecified extra-adrenal pheochromocytoma patient who used beta-blocker

An operation was planned for a female patient aged 59 for intra-abdominal mass. The patient was using nebivolol for hypertension. Blood pressure (BP) of the patient was raised to 200/130 mmHg during anesthesia induction. BP was gradually reduced by remifentanil infusion. Following the manipulation of the mass, BP began to increase (225/160 mmHg), thus nitroglycerin and followed nitroprusside infusion was started. Propofol (200 + 200 mg) and furosemide (20 mg) were administered intravenously. BP suddenly dropped (90/60 mmHg) following the removal of the mass, nitroglycerine, and nitroprusside infusions were stopped; remifentanil dose was decreased and fluid was quickly infused. The patient was uneventually recovered. Vanilmandelic acid level was higher in the patient and pheochromocytoma was considered.

Time and technology will tell: the pathophysiologic basis of neurohormonal modulation in heart failure

The central roles of neurohormonal abnormalities in the pathobiology of heart failure have been defined in recent decades. Experiments have revealed both systemic involvement and intricate subcellular regulation by circulating effectors of the sympathetic nervous system, the renin-angiotensin-aldosterone system, and others. Randomized clinical trials substantiated these findings, establishing neurohormonal antagonists as cornerstones of heart failure pharmacotherapy, and occasionally offering further insight on mode of benefit. This review discusses the use of β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone receptor antagonists in the treatment of heart failure, with particular attention to the pathophysiologic basis and mechanisms of action.

Multicentric study on the beta-blocker use and relation with exacerbations in COPD

Chronic obstructive pulmonary disease (COPD) is frequently associated with chronic heart failure (CHF) or coronary artery disease (CAD). In spite of the recommendation to use beta-blockers (BB) they are likely under-prescribed to patients with concurrent COPD and heart diseases. To find out the prevalence of use of BB, 256 COPD patients were consecutively recruited by pulmonary physicians from 14 hospitals in 7 regions of Spain in their outpatient offices if they had a diagnosis of COPD, were not on long-term oxygen therapy, had CHF or CAD, and met the criteria for BB treatment. In patients with indication 58% (95%CI, 52-64%) of the COPD patients and 97% of the non-COPD patients were on BB (p < 0.001). In patients with COPD, several factors were independently related to at least one visit to the emergency room in the previous year such as use of BB, adjusted OR = 0.27 (95% CI 0.15-0.50), GOLD stage D, OR = 2.52 (1.40-4.53), baseline heart rate >70, OR 2.19 (1.24-3.86) use of long-acting beta2-agonists OR = 2.18 (1.29-3.68), previous episodes of left ventricular failure OR 2.27 (1.19-4.33) and diabetes, OR = 1.82 (1.08-3.38). We conclude that, according to what is recommended by current guidelines, BB are still under-prescribed in COPD patients. COPD patients with CHF or CAD using BB suffer fewer exacerbations and visits to the ER. GOLD stage, use of long-acting beta2-agonists, baseline heart rate and comorbidities are also risk factors for exacerbations in this population.

Systolic heart failure: knowledge gaps, misconceptions, and future directions

BACKGROUND

Systolic heart failure is the final manifestation of several cardiovascular conditions. The 2001 American College of Cardiology/American Heart Association guidelines depicting the progression of heart failure (HF) from stage A through stage D are aimed at the early treatment of risk factors. However, treatment is often delayed until stage C, and as a result HF continues to impose a major burden on our healthcare industry.

METHODS

We conducted an extensive literature review of the MEDLINE/PubMed database with the purpose of elucidating knowledge gaps and misconceptions regarding systolic HF.

RESULTS

Long-term beta adrenergic blocking is the only pharmacologic intervention that reverses left ventricular remodeling. Whether beta adrenergic blocking prevents or delays left ventricular remodeling in patients at risk of HF is presently unknown. A knowledge gap also exists regarding the phenotype of patients that derives a mortality benefit from implantable cardioverter defibrillator therapy. Acute decompensated HF is a misnomer because patients with chronic HF are known to be deteriorating in the weeks preceding hospitalization. Functional class and ejection fraction are not closely correlated. Advanced HF therapies such as heart transplantation and mechanical circulatory support are available to an extremely small fraction of patients with systolic HF.

CONCLUSION

Concentrating efforts on the early stages of the disease process with optimal management of risk factors for HF is critical to having a significant impact on this ongoing pandemic.

Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services

Pulmonary disease is common in patients with heart failure, through shared risk factors and pathophysiological mechanisms. Adverse pulmonary vascular remodelling and chronic systemic inflammation characterize both diseases. Concurrent chronic obstructive pulmonary disease presents diagnostic and therapeutic challenges, and is associated with increased morbidity and mortality. The cornerstones of therapy are beta-blockers and beta-agonists, whose pharmacological properties are diametrically opposed. Each disease is implicated in exacerbations of the other condition, greatly increasing hospitalizations and associated health care costs. Such multimorbidity is a key challenge for health-care systems oriented towards the treatment of individual diseases. Early identification and treatment of cardiopulmonary disease may alleviate this burden. However, diagnostic and therapeutic strategies require further validation in patients with both conditions.

Oral ascorbic acid in combination with beta-blockers is more effective than beta-blockers alone in the prevention of atrial fibrillation after coronary artery bypass grafting

Because adrenergic beta antagonists are not sufficient to prevent atrial fibrillation after coronary artery bypass grafting, this prospective, randomized trial was designed to evaluate the effects of ascorbic acid as an adjunct to beta-blockers. Fifty patients formed our ascorbic acid group, and another 50 patients formed our control group. All patients were older than 50 years, were scheduled to undergo coronary artery bypass grafting, and had been treated with beta-blockers for at least 1 week before surgery. The mean age of the population was 60.19+/-7.14 years; 67% of the patients were men. Patients in the ascorbic acid group received 2 g of ascorbic acid on the night before the surgery and 1 g twice daily for 5 days after surgery. Patients in the control group received no ascorbic acid. Patients in both groups continued to receive beta-blockers after surgery. Telemetry monitoring was performed in the intensive care unit, and Holter monitoring was performed for 4 days thereafter. The incidence of postoperative atrial fibrillation was 4% in the ascorbic acid group and 26% in the control group (odds ratio, 0.119; 95% confidence interval, 0.025-0.558, P = 0.002). We conclude that ascorbic acid is effective, in addition to being well-tolerated and relatively safe. Therefore, it can be prescribed as an adjunct to beta-blockers for the prophylaxis of post-bypass atrial fibrillation.