Beta-blockers in Hypertensive Left Ventricular Hypertrophy and Atrial Fibrillation Prevention.

BACKGROUND: Hypertensive left ventricular hypertrophy (HTN LVH) is a key risk factor for atrial fibrillation (AF). OBJECTIVE: To evaluate the possible role of beta-blockers (BBs) in addition to a renin-angiotensinaldosterone system (RAAS) blocker in AF prevention in patients with HTN LVH. METHODS: We performed a PubMed, Elsevier, SAGE, Oxford, and Google Scholar search with the search items 'beta blocker hypertension left ventricular hypertrophy patient' from 2013-2023. In the end, a 'snowball search', based on the references of relevant papers as well as from papers that cited them was performed. RESULTS: HTN LVH is a risk factor for AF. In turn, AF substantially complicates HTN LVH and contributes to the genesis of heart failure (HF) with preserved ejection fraction (HFpEF). The prognosis of HFpEF is comparable with that of HF with reduced EF (HFrEF), and, regardless of the type, HF is associated with five-year mortality of 50-75%. The antiarrhythmic properties of BBs are wellrecognized, and BBs as a class of drugs are - in general - recommended to decrease the incidence of AF in HTN. CONCLUSION: BBs are recommended (as a class) for AF prevention in several contemporary guidelines for HTN. LVH regression in HTN - used as a single criterion for the choice of antihypertensive medication - does not capture this protective effect. Consequently, it is worth studying how meaningful this antiarrhythmic action (to prevent AF) of BBs is in patients with HTN LVH in addition to a RAAS blocker.

A Need for Improvement in the Definition of Resistant Arterial Hypertension.

With the medical and social importance of resistant arterial hypertension (HTN) in mind, we had three goals in this paper: to study the definitions of resistant HTN in the guidelines on the topic, to analyze them, and to suggest some improvements. We found (at least) eleven insufficiencies in the definition of resistant HTN: (1) different blood pressure (BP) values are used for diagnoses; (2) the number of BP measurements is not specified; (3) the time-frame for the definition is not obtained; (4) it fails to provide normal or target or controlled BP values; (5) secondary HTN is not currently defined as true resistant HTN, but as apparently treatment-resistant HTN; (6) the definition usually directly incorporates BP cut-offs for systolic BP (sBP) and diastolic BP (dBP) making the diagnosis temporary; (7) stress is not included in the exclusion strategy for resistant HTN; (8) there is potentially a need to introduce a category of recovered resistant HTN; (9) to what degree do healthy lifestyle measures have to be fulfilled to consider it as sufficient to change the diagnosis from "apparent treatment-resistant HTN" to the "resistant HTN"; (10) sBP values normal-for-the-age for 61 and 81 year old patients in some guidelines fulfill the criterion for resistant HTN; (11) it probably ought to read "In the absence of contraindications and compelling indications…" in the others. We believe that it is better to use the phrase "above the target BP" for the definition of (treatment) resistant HTN, because the whole story of resistant HTN is related to non-responders to antihypertensive treatment. Therefore, as we treat to target and not to normal values, it is appropriate to define resistant HTN as an insufficiency to reach the target BP values. Moreover, the definition of (treatment) resistant HTN should not be universal for every patient with HTN, but it should be age-related: (treatment) resistant HTN is elevated BP over the target/normal BP values. Using this modification, there will be no need to automatically change the definition of resistant HTN when we change the BP targets in the future.

Beta Blockers can Mask not only Hypoglycemia but also Hypotension.

BACKGROUND: Beta-adrenergic (ß-AR) receptor blockers (BBs) are an essential class of drugs as they have numerous indications. On the other hand, they have numerous unwanted effects that decrease the compliance, adherence, and persistence of this very useful group of drugs. OBJECTIVE: The paper aims to analyze the possibility that an unnoticed side effect may contribute to a less favorable pharmacologic profile of BBs, e.g., a diminished reaction to a sudden fall in BP. METHODS: We searched two medical databases for abstracts and citations (Medline and SCOPUS). Moreover, we searched the internet for drug prescription leaflets (of the individual BBs). RESULTS: Whichever cause of stress is considered, the somatic manifestations of stress will be (partially) masked if a patient takes BB. Stress-induced hypercatecholaminemia acts on ß-AR of cardiomyocytes; it increases heart rate and contractility, effects suppressed by BBs. The answers of the organism to hypoglycemia and hypotension share the main mechanisms such as sympathetic nervous system activation and hypercatecholaminemia. Thus, there is a striking analogy: BBs can cover up symptoms of both hypoglycemia (which is widely known) and of hypotension (which is not recognized). It is widely known that BBs can cause hypotension. However, they can also complicate recovery by spoiling the defense mechanisms in hypotension as they interfere with the crucial compensatory reflex to increase blood pressure in hypotension. CONCLUSION: Beta blockers can cause hypotension, mask it, and make recovery more difficult. This is clinically important and deserves to be more investigated and probably to be stated as a warning.

By Discontinuing Beta-Blockers Before an Exercise Test, We may Precipitate a Rebound Phenomenon.

BACKGROUND: There is a need to analyse the current approach to beta-blocker (BB) use in relation to exercise-based stress tests. OBJECTIVE: We compared various guidelines regarding recommending abrupt vs. gradual discontinuation of BB prior to exercise tests. We also analyse the shortcomings of the currently recommended approach and suggest a new approach to avoid BB rebound. METHODS: A narrative review is used to analyse this topic due to the lack of valid randomized clinical trials. RESULTS: Omitting the BB therapy prior to exercise-based test has been recommended in guidelines for many years. Although reasonable, this approach has potential disadvantages since sudden BB withdrawal may induce a rebound phenomenon, which is also acknowledged in several guidelines. CONCLUSION: We observed inconsistency among relevant guidelines; there is no homogenous approach regarding BB use before exercise tests. Most guidelines recommend BB withdrawal for a couple of days before the test; they do not advise BB dose tapering. This approach is not standardised and raises the risk of BB rebound phenomenon before and during the test. Therefore, we suggest using half the prescribed BB dose at the usual time of administration (in the morning, prior to the exercise test).

Beta blocker rebound phenomenon is important, but we do not know its definition, incidence or optimal prevention strategies.

The aim of this review is to analyze whether there is a need for scientific information about the beta blocker (BB) rebound phenomenon; whether such information is available; and, if it is, how detailed is the BB rebound phenomenon explained in the guidelines and papers? A narrative review is used due to the lack of valid randomized clinical trials (RCTs) on the topic, which are needed for a meta-analysis. The BB rebound phenomenon can have dangerous consequences. The discontinuation of a BB leads to a fourfold increased risk of events related to coronary artery disease in hypertensive patients; it increases in-hospital mortality in heart failure patients; it can precipitate angina pectoris attack; and it increases the risk for death and rehospitalization in patients who survive acute myocardial infarction. Consequently, being considered in the guidelines, the BB rebound phenomenon is believed to be clinically relevant (by experts in the field). This is in sharp contrast with the lack of any additional relevant information about the BB rebound phenomenon in the various important guidelines. For example, we lack a consensus about the precise definition. Moreover, data about the incidence and optimal prevention strategies are lacking for the phenomenon (which is sometimes life-threatening). The BB rebound phenomenon is an additional reason why it is very important to test the prognosis of patients following the cessation of long-term medicaments in RCTs, particularly for BBs.

Should Cushing's Syndrome be Considered as a Disease with High Cardiovascular Risk in Relevant Guidelines?

A considerable amount of data supports a 1.8-7.4-fold increased mortality associated with Cushing's syndrome (CS). This is attributed to a high occurrence of several cardiovascular disease (CVD) risk factors in CS [e.g. adiposity, arterial hypertension (AHT), dyslipidaemia and type 2 diabetes mellitus (T2DM)]. Therefore, practically all patients with CS have the metabolic syndrome (MetS), which represents a high CVD risk. Characteristically, despite a relatively young average age, numerous patients with CS display a 'high' or 'very high' CVD risk (i.e. risk of a major CVD event >20% in the following 10 years). Although T2DM is listed as a condition with a high CVD risk, CS is not, despite the fact that a considerable proportion of the CS population will develop T2DM or impaired glucose tolerance. CS is also regarded as a risk factor for aortic dissection in current guidelines. This review considers the evidence supporting listing CS among high CVD risk conditions.