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1.
Int Heart J ; 61(5): 1044-1048, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32921663

RESUMO

Ivabradine is a selective inhibitor of the sinoatrial node "funny" current, prolonging the slow diastolic depolarization. As it has the ability to block the heart rate selectively, it is more effective at a faster heart rate. It is recommended for the treatment of heart failure reduced ejection fraction in the presence of beta-blocker therapy for the further reduction of the heart rate. However, previous reports have shown the association of Torsade de pointes (TdP) with concurrent use of ivabradine and drugs resulting in QT prolongation or blockage of the metabolic breakdown of ivabradine. In this article, we report two cases of patients with heart failure reduced ejection fraction who developed TdP after ivabradine use. Our report highlights the need to exercise caution with the administration of ivabradine in the presence of a reduced repolarization reserve, such as QT prolongation or metabolic insufficiency.


Assuntos
Fármacos Cardiovasculares/efeitos adversos , Insuficiência Cardíaca/tratamento farmacológico , Ivabradina/efeitos adversos , Torsades de Pointes/induzido quimicamente , Antagonistas Adrenérgicos beta/efeitos adversos , Interações Medicamentosas , Cardioversão Elétrica , Eletrocardiografia , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores de Simportadores de Cloreto de Sódio e Potássio/efeitos adversos , Volume Sistólico
2.
PLoS One ; 15(8): e0237781, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32857798

RESUMO

BACKGROUND: Drug therapy problems (DTPs) are major concerns of healthcare and have been identified to contribute to negative clinical outcomes. The occurrence of DTPs in heart failure patients is associated with worsening of outcomes. The aim of this study was to assess DTPs, associated factors and patient satisfaction among ambulatory heart failure patients at Tikur Anbessa Specialized Hospital (TASH). METHODS: A hospital based prospective cross-sectional study was conducted on 423 heart failure patients on follow up at TASH. Data was collected through patient interview and chart review. Descriptive statistics, binary and multiple logistic regressions were used for analyses and P < 0.05 was used to declare association. RESULTS: Majority of the patients were in NYHA class III (55.6%) and 66% of them had preserved systolic function. DTPs were identified in 291(68.8%) patients, with an average number of 2.51±1.07.per patient. The most common DTPs were drug interaction (27.3%) followed by noncompliance (26.2%), and ineffective drug use (13.7%). ß blockers were the most frequent drug class involved in DTPs followed by angiotensin converting enzyme inhibitors. The global satisfaction was 78% and the overall mean score of treatment satisfaction was 60.5% (SD, 10.5). CONCLUSION: Prevalence of DTPs as well as non-adherence among heart failure patients on follow up is relatively high. Detection and prevention of DTPs along with identifying patients at risk can save lives, help to adopt efficient strategies to closely monitor patients at risk, enhance patient's quality of life and optimize healthcare costs.


Assuntos
Antagonistas Adrenérgicos beta/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Insuficiência Cardíaca/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Adolescente , Antagonistas Adrenérgicos beta/farmacocinética , Adulto , Idoso , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina/farmacocinética , Estudos Transversais , Interações Medicamentosas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/psicologia , Etiópia/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Adesão à Medicação/psicologia , Pessoa de Meia-Idade , Ambulatório Hospitalar/estatística & dados numéricos , Prevalência , Estudos Prospectivos , Qualidade de Vida , Inquéritos e Questionários/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Adulto Jovem
3.
JAMA ; 324(3): 279-290, 2020 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-32692391

RESUMO

Importance: Perioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery. Observations: Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose ß-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without ß-blocker use; P = .005) and mortality (3.1% vs 2.3% without ß-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration. Conclusions and Relevance: Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.


Assuntos
Doenças Cardiovasculares/etiologia , Complicações Pós-Operatórias/etiologia , Medição de Risco/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas Adrenérgicos beta/efeitos adversos , Fatores Etários , Idoso , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Biomarcadores/sangue , Angiografia Coronária , Ecocardiografia Transesofagiana , Eletrocardiografia/métodos , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Insuficiência Cardíaca/diagnóstico , Doenças das Valvas Cardíacas/diagnóstico , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Isquemia Miocárdica/diagnóstico , Revascularização Miocárdica , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Stents/efeitos adversos , Acidente Vascular Cerebral/induzido quimicamente , Fatores de Tempo , Estados Unidos/epidemiologia
4.
Sr Care Pharm ; 35(8): 345-348, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32718390

RESUMO

In 2017, a total of 26,431 beta-blocker exposures were reported to United States poison centers, with 21% of adult exposures attributed to patients 60 years of age and older. Beta-blockers are a major component of therapy in numerous cardiovascular diseases, which have a higher incidence in older people. Along with polypharmacy and neurocognitive decline, potentially limiting reliable medication adherence, older patients may be more sensitive to the hypotensive and bradycardic effects of beta-blockers. Additionally, because of a lack of success of traditional management methods, evidence of newer therapies such as highdose insulin euglycemia therapy and intravenous lipid emulsion has shown success in various patient cases. This review seeks to summarize the mechanisms and effects of beta-blocker toxicity and review management strategies in older people.


Assuntos
Antagonistas Adrenérgicos beta/efeitos adversos , Emulsões Gordurosas Intravenosas , Humanos , Insulina , Insulina Regular Humana , Polimedicação , Estados Unidos
5.
Cardiovasc Ther ; 2020: 2509875, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32565908

RESUMO

Introduction: Beta-blocker use evaluation is a performance method that focuses on the evaluation of beta-blocker use processes to achieve optimal patient outcomes. Several studies conducted in different hospitals revealed a high incidence of inappropriate prescription of beta-blockers among hospitalized patients. Therefore, it is important to identify inappropriate beta-blocker prescribing since they may increase the risk of hospitalizations. Despite this, there was no study conducted related to drug use evaluation of beta-blockers in Nedjo general hospital (NGH). Thus, this study was aimed at assessing the use evaluation of beta-blockers in medical wards of NGH. Methods: A retrospective cross-sectional study was conducted at medical wards of NGH from January 1, 2016, to December 31, 2017. Results: Out of the total of 149 medical record of patients that contains beta-blockers, 84 (56.37%) were males and about one-third (31.54%) of the patients ages were between 41 and 50 years. Propranolol was the most commonly prescribed beta-blocker (62.76%), and 94.56% of beta-blockers were prescribed with correct indication. There were about 51%, 46.31%, 64.43%, and 46.98% of beta-blockers prescribed with the correct dose, duration, frequency, and route of administration, respectively. Regarding the routes of administration, 70 (46.98%) of them were prescribed with the correct route. Most drugs interacting were propranolol with cimetidine 26 (68.42%), and the most frequent condition for which beta-blockers were prescribed was hypertension (32.89%). Conclusion: Overall, there was an inappropriate use of beta-blockers in terms of dosage and durations. So, prescribers of NGH should strictly adhere to the national treatment guideline when prescribing medications. Additionally, drug information centers have proved useful and effective in promoting rational drug use. Hence, it should be recommended for general use.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Hospitais Gerais/tendências , Prescrição Inadequada/tendências , Serviço de Farmácia Hospitalar/tendências , Padrões de Prática Médica/tendências , Adolescente , Antagonistas Adrenérgicos beta/efeitos adversos , Adulto , Estudos Transversais , Interações Medicamentosas , Revisão de Uso de Medicamentos/tendências , Etiópia , Feminino , Fidelidade a Diretrizes/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Adulto Jovem
7.
N Engl J Med ; 382(25): 2441-2448, 2020 06 18.
Artigo em Inglês | MEDLINE | ID: covidwho-155188

RESUMO

BACKGROUND: There is concern about the potential of an increased risk related to medications that act on the renin-angiotensin-aldosterone system in patients exposed to coronavirus disease 2019 (Covid-19), because the viral receptor is angiotensin-converting enzyme 2 (ACE2). METHODS: We assessed the relation between previous treatment with ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium-channel blockers, or thiazide diuretics and the likelihood of a positive or negative result on Covid-19 testing as well as the likelihood of severe illness (defined as intensive care, mechanical ventilation, or death) among patients who tested positive. Using Bayesian methods, we compared outcomes in patients who had been treated with these medications and in untreated patients, overall and in those with hypertension, after propensity-score matching for receipt of each medication class. A difference of at least 10 percentage points was prespecified as a substantial difference. RESULTS: Among 12,594 patients who were tested for Covid-19, a total of 5894 (46.8%) were positive; 1002 of these patients (17.0%) had severe illness. A history of hypertension was present in 4357 patients (34.6%), among whom 2573 (59.1%) had a positive test; 634 of these patients (24.6%) had severe illness. There was no association between any single medication class and an increased likelihood of a positive test. None of the medications examined was associated with a substantial increase in the risk of severe illness among patients who tested positive. CONCLUSIONS: We found no substantial increase in the likelihood of a positive test for Covid-19 or in the risk of severe Covid-19 among patients who tested positive in association with five common classes of antihypertensive medications.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas de Receptores de Angiotensina/administração & dosagem , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Bloqueadores dos Canais de Cálcio/administração & dosagem , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Inibidores de Simportadores de Cloreto de Sódio/administração & dosagem , Antagonistas Adrenérgicos beta/efeitos adversos , Adulto , Idoso , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Anti-Hipertensivos/administração & dosagem , Anti-Hipertensivos/efeitos adversos , Teorema de Bayes , Betacoronavirus , Bloqueadores dos Canais de Cálcio/efeitos adversos , Feminino , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , New York , Pandemias , Pontuação de Propensão , Sistema Renina-Angiotensina/efeitos dos fármacos , Fatores de Risco , Inibidores de Simportadores de Cloreto de Sódio/efeitos adversos
8.
High Blood Press Cardiovasc Prev ; 27(4): 315-320, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32385789

RESUMO

INTRODUCTION: Previous observation identified both hypotension and arterial aging, indexed as Pulse Wave Velocity (PWV), as significant determinants of cognitive decline in older subjects. AIM: To investigate the role of PWV as a determinant of hypotension in older patients. METHODS: A cohort of 344 subjects came to our Outpatient Clinic, free of cancer, acute myocardial infarction or stroke, atrial fibrillation, renal, hepatic or cardiac failure, secondary hypertension, or thyroid disease. RESULTS: Hypotension occurred in 49% of participants. SBP levels (OR 0.79, 95% CI 0.67-0.84, p < 0.01), PWV (OR 0.86, 95% CI 0.77-0.94, p < 0.01), and use of beta-blockers (OR 2.42, 95% CI 1.09-5.36, p < 0.05), were independent determinants of the risk of hypotension. CONCLUSIONS: Hypotension is a quite common phenomenon in older subjects. Its prevention requires a more accurate management of hypertension aimed at better identifying which older subjects in whom intensive BP control may be harmful and those who may benefit from it.


Assuntos
Envelhecimento , Pressão Arterial , Hipotensão/etiologia , Rigidez Vascular , Antagonistas Adrenérgicos beta/efeitos adversos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Análise de Onda de Pulso , Medição de Risco , Fatores de Risco
9.
N Engl J Med ; 382(25): 2441-2448, 2020 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-32356628

RESUMO

BACKGROUND: There is concern about the potential of an increased risk related to medications that act on the renin-angiotensin-aldosterone system in patients exposed to coronavirus disease 2019 (Covid-19), because the viral receptor is angiotensin-converting enzyme 2 (ACE2). METHODS: We assessed the relation between previous treatment with ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium-channel blockers, or thiazide diuretics and the likelihood of a positive or negative result on Covid-19 testing as well as the likelihood of severe illness (defined as intensive care, mechanical ventilation, or death) among patients who tested positive. Using Bayesian methods, we compared outcomes in patients who had been treated with these medications and in untreated patients, overall and in those with hypertension, after propensity-score matching for receipt of each medication class. A difference of at least 10 percentage points was prespecified as a substantial difference. RESULTS: Among 12,594 patients who were tested for Covid-19, a total of 5894 (46.8%) were positive; 1002 of these patients (17.0%) had severe illness. A history of hypertension was present in 4357 patients (34.6%), among whom 2573 (59.1%) had a positive test; 634 of these patients (24.6%) had severe illness. There was no association between any single medication class and an increased likelihood of a positive test. None of the medications examined was associated with a substantial increase in the risk of severe illness among patients who tested positive. CONCLUSIONS: We found no substantial increase in the likelihood of a positive test for Covid-19 or in the risk of severe Covid-19 among patients who tested positive in association with five common classes of antihypertensive medications.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas de Receptores de Angiotensina/administração & dosagem , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Bloqueadores dos Canais de Cálcio/administração & dosagem , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Inibidores de Simportadores de Cloreto de Sódio/administração & dosagem , Antagonistas Adrenérgicos beta/efeitos adversos , Adulto , Idoso , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Anti-Hipertensivos/administração & dosagem , Anti-Hipertensivos/efeitos adversos , Teorema de Bayes , Betacoronavirus , Bloqueadores dos Canais de Cálcio/efeitos adversos , Feminino , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , New York , Pandemias , Pontuação de Propensão , Sistema Renina-Angiotensina/efeitos dos fármacos , Fatores de Risco , Inibidores de Simportadores de Cloreto de Sódio/efeitos adversos
10.
Life Sci ; 252: 117649, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32275936

RESUMO

Chronic obstructive pulmonary disease (COPD) with cardiovascular complications is very common. Due to fear of exacerbating airway spasm, ß-blockers are rarely used in such patients. Many observational studies suggest that ß-blockers can reduce the disease progression and the risk of mortality in patients with COPD, but lack of confirmation from randomized controlled trials. This article reviews the application of ß-blockers in patients with COPD based on the results of the latest published randomized controlled trials.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Doenças Cardiovasculares/prevenção & controle , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Antagonistas Adrenérgicos beta/efeitos adversos , Progressão da Doença , Humanos , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Ensaios Clínicos Controlados Aleatórios como Assunto
11.
Curr Opin Anaesthesiol ; 33(3): 417-422, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32324663

RESUMO

PURPOSE OF REVIEW: Although the indications for ß-blockers in the management of patients with congestive heart failure and myocardial infarction are well established, the use of ß-blockers in the perioperative setting remains controversial. RECENT FINDINGS: Since 2008 PeriOperative ISchemic Evaluation Trial, there have been numerous studies suggesting that perioperative ß-blockers are associated with adverse events such as hypotension, bradycardia, increased mortality, and stroke. SUMMARY: In this article, we review the most recent evidence to suggest an approach to perioperative ß-blocker use tailored to patient and surgical risk factors. We also review recent studies on off-label uses for perioperative ß-blockers.


Assuntos
Antagonistas Adrenérgicos beta/efeitos adversos , Anestesiologia/métodos , Doenças Cardiovasculares/induzido quimicamente , Cuidados Intraoperatórios/métodos , Complicações Pós-Operatórias/induzido quimicamente , Antagonistas Adrenérgicos beta/uso terapêutico , Bradicardia/induzido quimicamente , Humanos , Hipotensão/induzido quimicamente , Infarto do Miocárdio/induzido quimicamente , Assistência Perioperatória , Período Perioperatório , Fatores de Risco , Acidente Vascular Cerebral/induzido quimicamente
12.
Circ Cardiovasc Qual Outcomes ; 13(3): e006180, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32148101

RESUMO

BACKGROUND: To combat the high cost and increasing burden of quality reporting, the Medicare Payment Advisory (MedPAC) has recommended using claims data wherever possible to measure clinical quality. In this article, we use a cohort of Medicare beneficiaries with heart failure with reduced ejection fraction and existing quality metrics to explore the impact of changes in quality metric methodology on measured quality performance, the association with patient outcomes, and hospital rankings. METHODS AND RESULTS: We used 100% Medicare Parts A and B and a random 40% sample of Part D from 2008 to 2015 to create (1) a cohort of 295 494 fee-for-service beneficiaries with ≥1 hospitalization for heart failure with reduced ejection fraction and (2) a cohort of 1079 hospitals with ≥11 heart failure with reduced ejection fraction admissions in 2014 and 2015. We used Part D data to calculate ß-blocker use after discharge and ß-blocker use over time. We then varied the quality metric methodologies to explore the impact on measured performance. We then used multivariable time-to-event analyses to explore the impact of metric methodology on the association between quality performance and patient outcomes and Kendall's Tau to describe impact of quality metric methodology on hospital rankings. We found that quality metric methodology had a significant impact on measured quality performance. The association between quality performance and readmissions was sensitive to changes in methodology but the association with 1-year mortality was not. Changes in quality metric methodology also had a substantial impact on hospital quality rankings. CONCLUSIONS: This article highlights how small changes in quality metric methodology can have a significant impact on measured quality performance, the association between quality performance and utilization-based outcomes, and hospital rankings. These findings highlight the need for standardized quality metric methodologies, better case-mix adjustment and cast further doubt on the use of utilization-based outcomes as quality metrics in chronic diseases.


Assuntos
Demandas Administrativas em Assistência à Saúde , Antagonistas Adrenérgicos beta/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Alta do Paciente/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Volume Sistólico , Função Ventricular Esquerda , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Confiabilidade dos Dados , Bases de Dados Factuais , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Medicare/normas , Readmissão do Paciente/normas , Melhoria de Qualidade/normas , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
13.
Cardiovasc Drugs Ther ; 34(2): 215-221, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32219664

RESUMO

Beta blockers and renin-angiotensin-aldosterone-inhibitors (RAAS-i) including angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) have been a mainstay of guideline-based medical therapy for heart failure with reduced ejection fraction (HFrEF) for decades. However, initial evidence supporting each of the aforenoted class of drug for heart failure indications was largely found independently of the other two classes with the exception of the addition of BBs to ACEIs. In the initial ACEI trials for HFrEF, few participants were on BBs as BBs were seen as contraindicated in HFrEF at the time. The seminal BB in HFrEF trials had high prevalence of ACEIs use as ACEIs for HF were standard of care by then, but ARBs as a class were still in their infancy. We closely examine the evidence for combinations of BB and ACEIs versus ARBs in HFrEF. In doing so, we demonstrate the lack of evidence for consideration of ARBs to be interchangeable with ACEIs when used in combination with BB and provide evidence that calls in to question the validity of assuming benefits from each drug class are independently cumulative, widening the gap between ACEIs and ARBs when used with BBs. Modern guidelines should emphasize this lack of evidence for the combination use of ARB and BB in HFrEF, except for candesartan. Even as practice moves towards the widespread uptake of angiotensin receptor-neprilysin inhibitors (which contain the ARB valsartan) in heart failure, the distinction has important implications for the ongoing role of combination therapy with BB, which thus far has been assumed, but not proven.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Sistema Renina-Angiotensina/efeitos dos fármacos , Antagonistas Adrenérgicos beta/efeitos adversos , Antagonistas de Receptores de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Medicina Baseada em Evidências , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Equivalência Terapêutica , Resultado do Tratamento
14.
J Cardiovasc Pharmacol ; 75(3): 250-258, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31895871

RESUMO

Heart failure (HF) is highly prevalent and a major cause of death in the United States. The effect of HF medications on survival has been predicted by validated models studied in populations predominantly of European descent. This study aimed to identify medications associated with survival in a racially diverse HF population. Patients with HF were recruited and followed from 2001 to 2015. Data were collected from electronic health records and the Social Security Death Index. The primary analysis tested the association between medication dose and all-cause mortality, with a secondary analysis assessing the composite outcome of death or cardiac-related hospitalization. Circulating concentration of the fibrotic marker procollagen type III N-terminal peptide (PIIINP) was also compared with medication doses in patients with concentrations available. The study population consisted of 337 patients, of which 25.2% died and 46% were hospitalized. Increased beta-blocker (BB) dose was significantly associated with survival in the base model [hazard ratio (HR) = 0.71, P = 0.017] and marginally associated in the comprehensive model (HR = 0.75, P = 0.068). BB dose was also associated with decreased risk of the composite end point in the base model (HR = 0.80, P = 0.029) and to a lesser extent in the comprehensive model (HR = 0.83, P = 0.085). Furthermore, increased BB dose was inversely associated with circulating PIIINP concentration (P = 0.041). In conclusion, our study highlights the importance of BB dose escalation for survival and decreased hospitalization in patients with HF, regardless of race or HF type. It also suggests that benefits observed with high-dose BBs could be mediated, at least in part, by decreased cardiac fibrosis.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Biomarcadores/sangue , Causas de Morte , Chicago/epidemiologia , Feminino , Fibrose , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etnologia , Insuficiência Cardíaca/mortalidade , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Fragmentos de Peptídeos/sangue , Prevalência , Pró-Colágeno/sangue , Fatores de Proteção , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
BMC Cardiovasc Disord ; 20(1): 8, 2020 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-31918676

RESUMO

BACKGROUND: Ischemic cardiomyopathy is a high-cost, resource-intensive public health burden that is associated with a 1-year mortality rate of about 16% in western population. Different in patient ethnicity and pattern of practice may impact the clinical outcome. We aim to determine 1-year mortality and to identify factors that significantly predicts 1-year mortality of Thai patients with ischemic cardiomyopathy. METHODS: This prospective multicenter registry enrolled consecutive Thai patients that were diagnosed with ischemic cardiomyopathy at 9 institutions located across Thailand. Patients with left ventricular function < 40% and one of the following criteria were included: 1) presence of epicardial coronary stenoses > 75% in the left main or proximal left anterior descending artery or coronary angiography, and/or two major epicardial coronary stenoses; 2) prior myocardial infarction; 3) prior revascularization by coronary artery bypass graft or percutaneous coronary intervention; or, 4) magnetic resonance imaging pattern compatible with ischemic cardiomyopathy. Baseline clinical characteristics, coronary and echocardiographic data were recorded. The 1-year clinical outcome was pre-specified. RESULTS: Four hundred and nineteen patients were enrolled. Thirty-nine patients (9.9%) had died at 1 year, with 27 experiencing cardiovascular death, and 12 experiencing non-cardiovascular death. A comparison between patients who were alive and patients who were dead at 1 year revealed lower baseline left ventricular ejection fraction (LVEF) (26.7 ± 7.6% vs 30.2 ± 7.8%; p = 0.021), higher left ventricular end-diastolic volume (LVEDV) (185.8 ± 73.2 ml vs 155.6 ± 64.2 ml; p = 0.014), shorter mitral valve deceleration time (142.9 ± 57.5 ml vs 182.4 ± 85.7 ml; p = 0.041), and lower use of statins (94.7% vs 99.7%; p = 0.029) among deceased patients. Patients receiving guideline-recommended ß-blockers had lower mortality than patients receiving non-guideline-recommended ß-blockers (8.1% vs 18.2%; p = 0.05). CONCLUSIONS: The results of this study revealed a 9.9% 1-year mortality rate among Thai ischemic cardiomyopathy patients. Doppler echocardiographic parameters significantly associated with 1-year mortality were LVEF, LVEDV, mitral E velocity, and mitral valve deceleration time. The use of non-guideline-recommended ß-blockers rather than guideline recommended ß-blockers were associated with increased with 1-year mortality. Guidelines recommended ß-blockers should be preferred. TRIAL REGISTRATION: Thai Clinical Trials Registry TCTR20190722002. Registered 22 July 2019. "Retrospectively registered".


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Cardiomiopatias , Ecocardiografia Doppler/normas , Fidelidade a Diretrizes/normas , Isquemia Miocárdica , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Cardiomiopatias/diagnóstico por imagem , Cardiomiopatias/tratamento farmacológico , Cardiomiopatias/mortalidade , Cardiomiopatias/fisiopatologia , Causas de Morte , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/tratamento farmacológico , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/fisiopatologia , Valor Preditivo dos Testes , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Volume Sistólico/efeitos dos fármacos , Tailândia , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda/efeitos dos fármacos
16.
Vascul Pharmacol ; 125-126: 106649, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31958512

RESUMO

There are a few studies that report cognitive impairment as a complication of treatment with beta- blockers. We aimed to evaluate the longitudinal association between use of beta-blockers, as a class, and incident risk of all-cause dementia, vascular dementia, Alzheimer's and mixed dementia in the prospective population-based Malmö Preventive Project. We included 18,063 individuals (mean age 68.2, males 63.4%) followed up for 84,506 person-years. Dementia cases were retrieved from the Swedish National Patient Register and validated by review of medical records and neuroimaging data. We performed propensity score matching analysis, resulting in 3720 matched pairs of beta-blocker users and non-users at baseline, and multivariable Cox proportional-hazards regression. Overall, 122 study participants (1.6%) were diagnosed with dementia during the follow-up. Beta-blocker therapy was independently associated with increased risk of developing vascular dementia, regardless of confounding factors (HR: 1.72, 95%CI 1.01-3.78; p = .048). Conversely, treatment with beta-blockers was not associated with increased risk of all-cause, Alzheimer's and mixed dementia (HR:1.15; 95%CI 0.80-1.66; p = .44; HR:0.85; 95%CI 0.48-1.54; P = .59 and HR:1.35; 95%CI 0.56-3.27; p = .50, respectively). We observed that use of beta-blockers, as a class, is associated with increased longitudinal risk of vascular dementia in the general elderly population, regardless of cardiovascular risk factors, prevalent or incident history of atrial fibrillation, stroke, coronary events and heart failure. Further studies are needed to confirm our findings in the general population and to explore the mechanisms underlying the relationship between use of beta- blockers and increased risk of vascular dementia.


Assuntos
Antagonistas Adrenérgicos beta/efeitos adversos , Doenças Cardiovasculares/tratamento farmacológico , Sistema Cardiovascular/efeitos dos fármacos , Cognição/efeitos dos fármacos , Demência Vascular/induzido quimicamente , Idoso , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/fisiopatologia , Sistema Cardiovascular/fisiopatologia , Demência Vascular/diagnóstico , Demência Vascular/epidemiologia , Demência Vascular/psicologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Suécia/epidemiologia , Fatores de Tempo
17.
Lancet Neurol ; 19(3): 247-254, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31999942

RESUMO

BACKGROUND: ß-adrenoceptors are widely expressed in different human organs, mediate important body functions and are targeted by medications for various diseases (such as coronary heart disease and heart attack) and many ß-adrenoceptor acting drugs are listed on the WHO Model List of Essential Medicines. ß-adrenoceptor antagonists are used by billions of patients with neurological disorders, primarily for the treatment of migraine and action tremor (mainly essential tremor), worldwide. RECENT DEVELOPMENTS: An observational study reported a link between the chronic use of the ß-adrenoceptor antagonist propranolol and an increased risk of Parkinson's disease, while the chronic use of the ß-adrenoceptor agonists was associated with a decreased risk. Further support of this association was provided by a dose-dependent decrease in the risk of Parkinson's disease with chronic ß-adrenoceptor agonist (eg, salbutamol) use, and by functional data indicating a possible underlying molecular mechanism. Five additional epidemiological studies have examined the modulation of the risk of Parkinson's disease as a result of the use of ß-adrenoceptor-acting drugs in different populations. Overall, similar estimates but different interpretations of the associations were provided. Several findings suggest that the increase in risk of Parkinson's disease associated with ß-adrenoceptor antagonists use can be explained by reverse causation because prodromal Parkinson's disease is often associated with non-specific action tremor, which is usually treated with propranolol. The lower risk of Parkinson's disease seen in patients receiving ß-adrenoceptor agonists is likely to be indirectly mediated by smoking because smoking has a strong inverse association with Parkinson's disease (people that smoke have a reduced risk of developing Parkinson's disease). Smoking also causes chronic obstructive pulmonary disease, which is treated with ß-adrenoceptor-agonist medications. Even if causal, the effect of ß-adrenoceptor antagonists on the risk of Parkinson's disease would be small compared with other Parkinson's disease risk factors and would be similar to the risk evoked by pesticide exposure. The estimated risk of Parkinson's disease because of ß-adrenoceptor antagonists use corresponds to one case in 10 000 patients after 5 years of propranolol use, and would be considered a very rare adverse effect. Thus, not using ß-adrenoceptor antagonists would severely harm patients with recommended indications, such as heart disease or migraine. Similarly, 50 000 people would have to be treated for 5 years with salbutamol to prevent Parkinson's disease in one patient, suggesting that primary preventive therapy studies on disease modification are not warranted. WHERE NEXT?: Epidemiological evidence for a causal relationship between use of ß2-adrenoceptor antagonists and the increased risk of Parkinson's disease is weak, with other explanations for the association being more probable. Future observational studies are warranted to clarify this association. However, given the very low risk associated with propranolol, most clinicians are unlikely to change their treatment approach.


Assuntos
Antagonistas Adrenérgicos beta/efeitos adversos , Doença de Parkinson/tratamento farmacológico , Receptores Adrenérgicos beta/metabolismo , Agonistas Adrenérgicos beta/uso terapêutico , Antagonistas Adrenérgicos beta/uso terapêutico , Humanos , Doença de Parkinson/metabolismo , Doença de Parkinson/fisiopatologia , Propranolol/efeitos adversos , Propranolol/uso terapêutico , Fatores de Risco , Transdução de Sinais
18.
Anesthesiology ; 132(2): 267-279, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31939841

RESUMO

BACKGROUND: For cardiac surgery patients under chronic ß-blocker therapy, guidelines recommend their early postoperative reintroduction to decrease the incidence of postoperative atrial fibrillation. The authors hypothesized that the timing of ß-blocker reintroduction affects their effectiveness on the incidence of postoperative atrial fibrillation. METHODS: This multicenter prospective French cohort study included patients on ß-blockers (more than 30 days before surgery) in sinus rhythm without a pacemaker. The primary outcome, time sequence of ß-blocker reintroduction, was analyzed for 192 h after surgery. The secondary outcome, relationship between the occurrence of postoperative atrial fibrillation and timing of ß-blocker reintroduction, was analyzed based on pre- and intraoperative predictors (full and selected sets) according to landmark times (patients in whom atrial fibrillation occurred before a given landmark time were not analyzed). RESULTS: Of 663 patients, ß-blockers were reintroduced for 532 (80%) but for only 261 (39%) patients in the first 48 h after surgery. Median duration before reintroduction was 49.5 h (95% CI, 48 to 51.5 h). Postoperative atrial fibrillation or death (N = 4) occurred in 290 (44%) patients. After performing a landmark analysis to take into account the timing of ß-blocker reintroduction, the adjusted odds ratios (95% CI) for predictor full and selected (increased age, history of paroxysmal atrial fibrillation, and duration of aortic cross clamping) sets for the occurrence of postoperative atrial fibrillation were: adjusted odds ratio (full) = 0.87 (0.58 to 1.32; P = 0.517) and adjusted odds ratio (selected) = 0.84 (0.58 to 1.21; P = 0.338) at 48 h; adjusted odds ratio (full) = 0.64 (0.39 to 1.05; P = 0.076) and adjusted odds ratio (selected) = 0.58 (0.38 to 0.89; P = 0.013) at 72 h; adjusted odds ratio (full) = 0.58 (0.31 to 1.07; P = 0.079) and adjusted odds ratio (selected) = 0.53 (0.31 to 0.91; P = 0.021) at 96 h. CONCLUSIONS: ß-Blockers were reintroduced early (after less than 48 h) in fewer than half of the cardiac surgery patients. Reintroduction decreased postoperative atrial fibrillation occurrence only at later time points and only in the predictor selected set model. These results are an incentive to optimize (timing, doses, or titration) ß-blocker reintroduction after cardiac surgery.


Assuntos
Antagonistas Adrenérgicos beta/administração & dosagem , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/tendências , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Antagonistas Adrenérgicos beta/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Estudos de Coortes , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Estudos Prospectivos
19.
Am Heart J ; 220: 51-58, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31783279

RESUMO

BACKGROUND: Rates and predictors of major bleeding in patients with peripheral artery disease (PAD) treated with antiplatelets have not been well studied. This post hoc analysis of EUCLID aimed to determine the incidence of major/minor bleeding, predictors of major bleeding, and risk of major adverse cardiovascular events (MACE) following major bleeding events. METHODS: EUCLID, a multicenter randomized controlled trial of 13,885 patients with symptomatic PAD, compared ticagrelor with clopidogrel for the prevention of MACE. The primary safety end point was Thrombolysis in Myocardial Infarction (TIMI) major bleeding. Baseline characteristics were used to develop a multivariable model to determine factors associated with TIMI major bleeding. The occurrence and timing of MACE relative to a first major bleeding event were determined. RESULTS: TIMI major bleeding occurred in 2.3% of participants overall (0.94 event/100 patient-years). There was no significant difference in major bleeding rates by treatment assignment. Factors associated with TIMI major bleeding included older age, geographic region, Rutherford class, and ß-blocker use. Patients with TIMI major bleeding postrandomization had an increased risk of MACE (hazard ratio [HR] 4.46; 95% CI 3.40-5.84; P < .0001) compared with those without major bleeding; the association was strongest within 30 days after a bleeding event. CONCLUSIONS: In patients with symptomatic PAD, 0.94 major bleeding event/100 patient-years was observed and associated with older age, residing in North America, disease severity, and ß-blocker use. Patients who had a major bleeding event were significantly more likely to experience MACE, especially within the first 30 days, when compared with patients who did not have major bleeding.


Assuntos
Doenças Cardiovasculares/etiologia , Clopidogrel/uso terapêutico , Hemorragia/epidemiologia , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Ticagrelor/uso terapêutico , Antagonistas Adrenérgicos beta/efeitos adversos , Antagonistas Adrenérgicos beta/uso terapêutico , Fatores Etários , Idoso , Método Duplo-Cego , Feminino , Hemorragia/complicações , Humanos , Incidência , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Características de Residência , Fatores de Risco , Fatores de Tempo
20.
Pediatrics ; 145(1)2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31852735

RESUMO

Nadolol is a ß-adrenergic antagonist that has been shown to be efficacious in the treatment of infantile hemangioma. It has been suggested that this drug may have fewer side effects compared with the gold standard therapy, propranolol, because it does not exhibit membrane-stabilizing effects and has little ability to cross the blood-brain barrier. However, the pharmacokinetics and safety of nadolol in infants are not well understood, potentially making this therapy dangerous. ß-adrenergic antagonist toxicity causes bradycardia, hypotension, hypoglycemia, and even death. We report a case of a 10-week-old girl who was started on nadolol for infantile hemangioma, died 7 weeks later, and was found to have an elevated postmortem cardiac blood nadolol level of 0.94 mg/L. The infant had no bowel movements for 10 days before her death, which we hypothesize contributed to nadolol toxicity. Pharmacokinetics studies show a large fraction of oral nadolol either remains in the feces unchanged or is excreted into feces via the biliary system, allowing continued absorption over time in infants who stool infrequently. Propranolol may be a safer therapy overall. Not only does it have a shorter half-life, but propranolol is hepatically metabolized and renally eliminated, allowing for less drug accumulation in healthy infants with variable stooling patterns. We suggest that if nadolol is selected for therapy, pediatricians should instruct parents to monitor their infants' bowel movements closely and encourage early intervention in the event of decreased stooling. This intervention may greatly improve the safety of nadolol in this vulnerable patient population.


Assuntos
Antagonistas Adrenérgicos beta/efeitos adversos , Neoplasias Faciais/tratamento farmacológico , Hemangioma Capilar/tratamento farmacológico , Nadolol/efeitos adversos , Antagonistas Adrenérgicos beta/sangue , Constipação Intestinal/complicações , Neoplasias Faciais/sangue , Evolução Fatal , Feminino , Hemangioma Capilar/sangue , Humanos , Lactente , Nadolol/sangue
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