Selective And Nonselective Beta Blockers Pdf
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- Beta-Adrenoceptor Antagonists (Beta-Blockers)
- Preferred beta-blockers for the treatment of heart failure
- Beta blockers
- Beta blocker
Carvedilol and nebivolol are the third generation beta blockers of choice for heart failure together with the second generation beta blockers bisoprolol and metoprolol succinate. Beta-adrenergic receptor blockers play an important role in the management of cardiovascular disease, including hypertension, ischemic heart disease and chronic heart failure. They differ, though, in beta-selectivity, vasodilation properties, and other ancillary features.
Beta-Adrenoceptor Antagonists (Beta-Blockers)
Metrics details. The associations of cardio-selective and non-selective agents on outcomes were adjusted for baseline characteristics using Cox proportional hazards. Exposure to cardio-selective and non-selective agents during the follow-up period was comparable, as measured by proportion of days covered 0. Peer Review reports. Given their high rates of hypertension and cardiovascular disease CVD [ 1 ], patients with end-stage renal disease ESRD on chronic dialysis often are prescribed medications [ 2 , 3 ] with cardioprotective properties [ 4 — 8 ].
However, when making a choice to prescribe a specific cardioprotective medication for hypertension in the setting of chronic dialysis, providers have to make clinically-relevant selections from a given drug class without having the benefit of a clear evidence base.
In the absence of clinical trial data, well-designed observational studies can provide important preliminary data on the relative effectiveness of different medications, particularly in a patient population widely excluded from trials. We used the dually eligible population because Medicare did not cover prescription medications during this time period. Outcomes assessed were all-cause mortality and a combined outcome that included cardiovascular mortality and morbidity.
From the USRDS, we obtained standard patient records that included information on demographics, comorbidities, functional status, and dialysis modality from the Medical Evidence Form, or CMS recorded at the time of dialysis commencement. The USRDS also incorporated Medicare paid inpatient and outpatient medical claims, a federally-funded program for which the vast majority of adults with end stage renal disease are enrolled [ 1 , 32 ]. Medicaid is a joint federal-state program designed to provide health care benefits to low-income persons: in the case of the dually eligible, Medicaid was the source of prescription drug coverage during the time period.
These sources were linked using previously described methodology [ 31 , 33 ] to permit identification of dually eligible dialysis patients in — To assure complete observability of the cohort, we employed several criteria as have also been described elsewhere [ 31 ]. Persons with coverage through the Veterans Administration and those who had previously been transplanted and returning to chronic dialysis were excluded.
Ohio residents were excluded since their claims do not include the days supplied of medication. Finally, we selected individuals who received at least one beta-blocker during their follow-up period. Subjects were then followed until they incurred a first outcome event death or cardiovascular event. Demographic and clinical variables, drawn from the CMS form, included age, sex, race by ethnicity, employment status, smoking status current at time of dialysis initiation , substance abuse alcohol or illicit drugs , ability to ambulate and to transfer, body mass index BMI , cause of ESRD, comorbidities, dialysis duration or vintage before medication initiation , and dialysis modality.
Ethnicity was categorized into one of four mutually exclusive groups: non-Hispanic Caucasians, non-Hispanic African-Americans, Hispanics, and Others. Cause of ESRD was categorized as diabetes, hypertension, glomerulonephritis, or other. Comorbidities consisted of diabetes, congestive heart failure, coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Because the CMS form is structured such that diabetes and hypertension may be considered either a cause of ESRD or a comorbidity, for the purposes of the present analysis, these two covariates were each considered a comorbidity if they were listed as either on the CMS form [ 34 , 35 ].
Dialysis modality at time of dialysis initiation was categorized as in-center hemodialysis or self-care dialysis home hemodialysis or peritoneal dialysis. However, switching was extremely rare: only 30 subjects switched from cardio-selective to non-selective agents and 28 subjects switched from non-selective to cardio-selective agent.
The proportion of days covered is computed from converting days supplied and dates from individual drug claims to a daily array. The proportion of days covered was adjusted for overlapping prescription fills, hospital, and skilled nursing facility days since medications administered throughout the institutionalization would not result in an outpatient drug claim.
In addition, we created a combined cardiovascular morbidity and mortality CVMM event outcome, capturing the first event per person. Cardiovascular-related mortality was derived from the USRDS listed cause of death myocardial infarction, atherosclerotic heart disease, cardiomyopathy, cardiac arrhythmia, cardiac arrest, cerebrovascular accidents.
For continuous measures, descriptive statistics were generated, stratified histograms were examined, and two-sample t -tests performed. To investigate within-class comparative effectiveness, we examined these data using Kaplan-Meier survival curves for an unadjusted comparison by stratifying by subclass.
We then fit Cox proportional hazards regression models for ACM and CVMM outcome to compare the subgroups, adjusting for potential confounding through covariate adjustment. Model sample sizes were different for two reasons. Cox proportionality assumptions were ascertained through visual assessment of the complementary log-log survival plots.
All statistical analyses were done with SAS 9. To test the robustness of our results, we performed several sensitivity analyses. This approach was selected because use of claims to determine true HF is particularly problematic in dialysis patients, with frequent misclassification of volume overload typically resulting from inadequate ultrafiltration or missed dialysis treatments as HF.
Of the initial 84, cohort, 52, with hypertension met criteria for observability Fig. More than one-third The CVMM model sample was slightly smaller at For the ACM model, new users included In the CVMM model, The overall distributions were quite comparable across both models, though, and as such we did not further adjust for proportion of days covered in the statistical models.
Nearly a third of each subclass cohort died, Cardiovascular causes accounted for CVMM rates HF accounted for Cerebrovascular events accounted for Kaplan-Meier survival curves for new users of beta-blockers.
Accordingly, we reported the models, above, without the interaction terms. Given the dearth of relevant literature, these findings constitute new insights for clinicians managing chronic dialysis patients. In an analysis of secondary data from Kaiser Permanente of Northern California, there were no significant differences in HF readmissions between metoprolol, atenolol, and carvedilol users with HF [ 29 ]. These studies, however, rarely included chronic dialysis patients, limiting their applicability to such patients.
In terms of pharmacokinetics, both are removed by dialysis. Carvedilol, labetalol, and metoprolol are moderately lipophilic [ 37 , 38 ]: the clinical implications of this would bias our findings toward the null since we considered metoprolol use in conjunction with atenolol.
Furthermore, rapid changes in drug levels associated with dialysis of more hydrophilic agents such as atenolol might also be theorized to predispose patients to sympathetic overload during the peri-dialysis period [ 38 ].
These theoretical issues, however, were not confirmed in our study. In fact, we observed the opposite impact. The clinical implications of this have never been fully explored, even though patients on hemodialysis can have tremendous shifts in potassium both during and between dialysis episodes.
Our study has several important limitations. First, as an observational study, our investigation cannot prove causality. The most obvious treatment selection concern is the presence of heart failure and the theoretical advantages offered by carvedilol.
We did lack important patient-level clinical measures such as blood pressure level and ejection fractions. These factors might be unbalanced between the treatment groups and, therefore, be a source of residual confounding. Nevertheless, the majority of observed differences between treatment groups at baseline were minimal, and there was also no apparent therapeutic advantage in the first year or so of follow-up, which suggests that there were no major differences in baseline clinical factors.
Any unmeasured, residual confounders would need to be both common and substantial to account for the large effect size that we observed in this study.
We did contemplate a propensity adjustment, but the distributions of measured, baseline factors were so well-balanced that the approach would not have afforded much benefit.
While the study period is dated, —, there have not been any major therapeutic breakthroughs within either subclass. Outpatient prescription medications were not covered under Medicare during this period, requiring us to use a Medicare-Medicaid eligible cohort. There is no physiologic reason to argue why dually enrolled beneficiaries would experience a different response as compared to the entire chronic dialysis population.
In fact, our study cohort was younger and included more women and minorities than most Medicare only cohorts, providing greater generalizability. These findings may reflect the different mechanisms of action of these two medication subclasses. The initiation of dialysis is an appropriate time for providers to reconsider the ideal antihypertensive regimen for their patients. United States Renal Data System.
Google Scholar. Impact of race on cumulative exposure to antihypertensive medications in dialysis. Am J Hypertens. Patterns in blood pressure medication use in US incident dialysis patients over the first 6 months. BMC Nephrol. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients.
N Engl J Med. Cardioprotection by HO, a novel verapamil derivative, targeted against ischemia and reperfusion-mediated acute myocardial infarction.
J Pharm Pharmacol. Carvedilol reduces elevated B-type natriuretic peptide in dialyzed patients without heart failure: cardioprotective effect of the beta-blocker. J Cardiovasc Pharmacol. Dargie HJ. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. Effect of carvedilol on survival in severe chronic heart failure. Beta-blocker treatment in heart failure. Fundam Clin Pharmacol. Beta-blockers and heart failure: meta-analysis of mortality trials.
Int J Clin Pharmacol Ther. Are beta-blockers as efficacious in patients with diabetes mellitus as in patients without diabetes mellitus who have chronic heart failure?
A meta-analysis of large-scale clinical trials. Am Heart J. Kidney Int. Cardiac medications and their association with cardiovascular events in incident dialysis patients: cause or effect? Benefits of aspirin and beta-blockade after myocardial infarction in patients with chronic kidney disease. Beta-blocker prescription and outcomes in hemodialysis patients from the Japan Dialysis Outcomes and Practice Patterns Study.
Preferred beta-blockers for the treatment of heart failure
Metrics details. The associations of cardio-selective and non-selective agents on outcomes were adjusted for baseline characteristics using Cox proportional hazards. Exposure to cardio-selective and non-selective agents during the follow-up period was comparable, as measured by proportion of days covered 0. Peer Review reports. Given their high rates of hypertension and cardiovascular disease CVD [ 1 ], patients with end-stage renal disease ESRD on chronic dialysis often are prescribed medications [ 2 , 3 ] with cardioprotective properties [ 4 — 8 ]. However, when making a choice to prescribe a specific cardioprotective medication for hypertension in the setting of chronic dialysis, providers have to make clinically-relevant selections from a given drug class without having the benefit of a clear evidence base.
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Non-selective beta blockers NSBB are commonly used to prevent portal hypertensive bleeding in cirrhotics. Nevertheless, in the last years, the use of NSBB in critically decompensated patients, especially in those with refractory ascites, has been questioned, mainly for an increased risk of mortality and worsening of systemic hemodynamics. Moreover, even if NSBB have been reported to correlate with a higher risk of renal failure and severe infection in patients with advanced liver disease and hypotension, their use has been associated with a reduction of risk of spontaneous bacterial peritonitis, modification of gut permeability and reduction of bacterial translocation. This manuscript systematically reviews the published evidences about harms and benefits of the use of NSBB in patients with decompensated cirrhosis. Cirrhosis is among the leading causes of death worldwide and hepatocellular carcinoma and complications of portal hypertension PH represent the most frequent causes of death.
Written and peer-reviewed by physicians—but use at your own risk. Read our disclaimer. Cardioselective blockers e.
Fabiana Aparecida Penachi Bosco, M. This study aimed at reviewing pharmacological and clinical information needed to prescribe b -blockers in perioperative medicine. CONTENTS: Selective b -blockers inhibit preferentially b 1 -receptors, decreasing heart rate and inotropism leading to less myocardial oxygen consumption. Non-selective b -blockers also inhibit b 2 -receptors, increasing bronchial and peripheral vascular resistance.
NCBI Bookshelf. Khashayar Farzam ; Arif Jan. Authors Khashayar Farzam 1 ; Arif Jan 2.
The application of cost-effectiveness methodology is particularly important in widespread diseases such as hypertension. However, because prospective costeffectiveness analyses comparing different antihypertensive drugs are not currently available, differences in the cost effectiveness of these drugs can only be estimated. The global costs of antihypertensive treatment are largely determined by drug costs. The adverse sequelae of hypertension include stroke, myocardial infarction, cardiac hypertrophy and renal failure.
Beta blockers are competitive antagonists that block the receptor sites for the endogenous catecholamines epinephrine adrenaline and norepinephrine noradrenaline on adrenergic beta receptors , of the sympathetic nervous system , which mediates the fight-or-flight response. Beta receptors are found on cells of the heart muscles, smooth muscles , airways , arteries , kidneys , and other tissues that are part of the sympathetic nervous system and lead to stress responses, especially when they are stimulated by epinephrine adrenaline. Beta-blockers interfere with the binding to the receptor of epinephrine and other stress hormones and weaken the effects of stress hormones. In , James Black  synthesized the first clinically significant beta blockers— propranolol and pronethalol ; it revolutionized the medical management of angina pectoris  and is considered by many to be one of the most important contributions to clinical medicine and pharmacology of the 20th century. For the treatment of primary hypertension, meta-analyses of studies which mostly used atenolol have shown that although beta blockers are more effective than placebo in preventing stroke and total cardiovascular events, they are not as effective as diuretics , medications inhibiting the renin—angiotensin system e. Large differences exist in the pharmacology of agents within the class, thus not all beta-blockers are used for all indications listed below. Beta-blockers have also been used for: [ citation needed ].
Перегрелся, подумал. Интересно, почему Стратмор его до сих пор не отключил. Ему понадобилось всего несколько мгновений, чтобы принять решение. Фонтейн схватил со стола заседаний трубку внутреннего телефона и набрал номер шифровалки. В трубке послышались короткие гудки. В сердцах он швырнул трубку на рычаг.
An article from the e-journal of the ESC Council for Cardiology Practice
Сбои техники в Третьем узле были такой редкостью, что номера ошибок в ее памяти не задерживалось. Сьюзан пролистала справочник и нашла нужный список. 19: ОШИБКА В СИСТЕМНОМ РАЗДЕЛЕ 20: СКАЧОК НАПРЯЖЕНИЯ 21: СБОЙ СИСТЕМЫ ХРАНЕНИЯ ДАННЫХ Наконец она дошла до пункта 22 и, замерев, долго всматривалась в написанное. Потом, озадаченная, снова взглянула на монитор. КОД ОШИБКИ 22 Сьюзан нахмурилась и снова посмотрела в справочник.
- Предупредите их о вирусе. Вы заместитель директора АНБ и обязаны победить. Стратмор медленно поднял голову и как человек, принимающий самое важное решение в своей жизни, трагически кивнул. Сьюзан решительно шагнула во тьму. ГЛАВА 87 Веспа выехала в тихий переулок Каретерра-де-Хуелва.
Вскоре спуск закончился, переключились какие-то шестеренки, и лифт снова начал движение, на этот раз горизонтальное. Сьюзан чувствовала, как кабина набирает скорость, двигаясь в сторону главного здания АНБ. Наконец она остановилась, и дверь открылась. Покашливая, Сьюзан неуверенно шагнула в темный коридор с цементными стенами. Она оказалась в тоннеле, очень узком, с низким потолком.
Шифровалка снова превратилась в затихшую черную пещеру. Скорее всего Северная Дакота попал в ловушку. Стратмор опустился на колени и повернул тяжелый винтовой замок. Теперь крышку не поднять изнутри. Подсобка компьютера надежно закрыта.
Сьюзан также сообщила, что интерес к криптографии появился у нее еще в школе, в старших классах.
Но вы же позвонили… Стратмор позволил себе наконец засмеяться. - Трюк, старый как мир. Никуда я не звонил. ГЛАВА 83 Беккеровская веспа, без сомнения, была самым миниатюрным транспортным средством, когда-либо передвигавшимся по шоссе, ведущему в севильский аэропорт.
Quien es. Кто он. - Понятия не имею.