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Beta Blockers Treatment For Cardiovascular Disease Where Do They Fit ?

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Beta Blockers Treatment For Cardiovascular Disease Where Do They Fit ?. Joseph Brent Muhlestein, MD, FACC. Co-Director of Cardiology Research, Intermountain Medical Center, Professor of Medicine, University of Utah. Nothing to Disclose. - PowerPoint PPT Presentation
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Beta Blockers Beta Blockers Treatment For Cardiovascular Disease Treatment For Cardiovascular Disease Where Do They Fit? Where Do They Fit? Joseph Brent Muhlestein, MD, FACC Co-Director of Cardiology Research, Intermountain Medical Center, Professor of Medicine, University of Utah Nothing to Disclose
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Page 1: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Beta BlockersBeta BlockersTreatment For Cardiovascular DiseaseTreatment For Cardiovascular Disease

Where Do They Fit? Where Do They Fit?

Joseph Brent Muhlestein, MD, FACCCo-Director of Cardiology Research, Intermountain Medical Center, Professor of Medicine, University of Utah

Nothing to Disclose

Page 2: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Introduction• Cardiovascular Disease is the major killer of the Western

World• Recently, significant successes have been made in

developing effective primary and secondary preventative therapies

• Surgery• Medicines• Life style changes• Some of these therapies have actually been shown to

save lives

Page 3: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Time (years)

No Symptoms ± Symptoms Symptoms

• Ischemic HeartDisease

• CerebrovascularDisease

• PeripheralVascularDisease

Schematic Timecourseof Human Atherogenesis

Page 4: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Pathogenesis of ACS

White HD. Am J Cardiol. 1997; 80(4A):2B-10B.

Page 5: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

The matrix skeleton of an unstablecoronary artery plaque

fissures inthe fibrous cap

Page 6: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Plaque rupture with thrombosisPlaque rupture with thrombosis

1 mm FJ Schoen, BWH

Thrombus Fibrous cap

Lipid coreLipid core

Page 7: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Plaque rupture

site

fatal thrombus

collagenous fibrous cap

thrombogenic lipid core

Page 8: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Characteristics of Unstable and Stable Plaques

Thin Thin Fibrous CapFibrous Cap

Inflammatory Inflammatory CellsCells

FewFewSMCsSMCs

UnstableUnstable

ErodedErodedEndotheliumEndotheliumActivatedActivated

MacrophagesMacrophages

ThickThickFibrous CapFibrous Cap

Lack ofLack ofInflammatory Inflammatory CellsCells

Foam CellsFoam Cells

IntactIntactEndothelium Endothelium

MoreMoreSMCsSMCs

StableStable

Libby et al. Circulation 1995; 91:2844-50

MMPMMP

Page 9: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Beta Blockers: Where do they fit?

Page 10: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Physiology of the Sympathetic Nervous

System• Epinephrine / Norepinephrine• Hypertension• Hypercoagulability• Vasoreacivity• Fibrosis• Upregulated in many situations• Emotional excitement• Heart Failure• General anesthesia

Page 11: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Beta Blockers: Indications• Post MI

• CAD• Heart Failure• Hypertension• Non-cardiac surgery• Rate Control

- Atrial fibrillation- Inappropriate sinus tachycardia

• Arrhythmias

Page 12: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Beta Blockers Post-MI• Rationale

- Antiplatelet effect- Antiarrhthmic effect- General blood pressure effect

Page 13: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Evidence of Beta Blockers post MI• Norwegian multicenter study group (1981)

- 17 month follow-up- Patients presenting with Q-wave MI- Timolol versus placebo- 44.6% reduction in sudden death- 39.3% reduction in total death

• Beta-blocker heart attack trial (1982)- 3 years follow-up- Patients presenting with Q-wave MI- Propranolol versus placebo- 26% reduction in total mortality

Page 14: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Beta Blockers post MI (cont.)• Metoprolol study (1981)

- 90 day follow-up- metoprolol versus placebo- 36% reduction in over-all mortality

• BBPP (1986, 9 trials pooled)- 13,679 patients, a variety of beta blocker drugs- 1 year follow-up- 24% reduction in death

• ISIS I (1986)- 16,027 patients, atenolol versus placebo- 20 months follow-up- 15% reduction in death

Page 15: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Effect on sudden death of beta blockade following MI. Pooled data

from 5 trials

Page 16: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Effect of Beta-Blackade on Mortality among High-Risk and

Low-risk Patients after MI• HCFA cooperative cardiovascular project• 201,752 patients post-MI abstracted• Mortality determined at 2 years post MI• 34% of all patients received beta blockers

Page 17: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

HCFA cooperative cardiovascular project:

Results2 Year Mortality Based on Initial EF

0%5%

10%15%20%25%30%35%40%

>50% 20-49% <20%

Mor

talit

y

Beta blocker No beta blocker

NEJM, 1998;339:489-97

Page 18: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

HCFA cooperative cardiovascular project:

Results2 Year Mortality Based on Type of MI

0%2%4%6%8%

10%12%14%

Q-wave Non Q-wave

Mor

talit

y

Beta blocker No beta blocker

NEJM, 1998;339:489-97

Page 19: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

LDS Hospital Data975 Patients with Angiographically Documented CAD Followed for >3 years

Mortality by whether post-MI patients (n=242) were placed on a beta blocker

6%

12%

0%2%4%6%8%

10%12%14%

Beta blocker No beta blocker

(P=0.19)

Page 20: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Beta Blockers in Heart Failure

Page 21: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Vicious Cycle of Heart Failure

Page 22: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

The Beginning of the Beta Blocker Story• 1985, LDS Hospital, Jeffrey Anderson, et al

• 50 patients with IDC (EF<30%)• Randomized to metoprolol (12.5-50 mg bid)

versus placebo• Followed for 18 months• Results

- Low dose beta blockade tolerated by 80% of patients

- Death: metoprolol = 3, placebo = 8- Significant improvement in functional class

Page 23: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Metoprolol in Idiopathic Dilated Cardiomyopathy

(MDC) Study• 383 patients with IDC (LVEF<40%)• 90% were NYHA class II-III• Randomized to metoprolol or Placebo• (target doses: 50-75 mg po bid)• Follow-up: One year• Primary endpoint: Death or need for

transplant• Secondary endpoint: EFLancet, 1993, 342(8885):1441-1446

Page 24: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Death or Transplant

Page 25: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Change In Ejection Fraction

Page 26: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Change in Functional Status

Page 27: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Study Results

Page 28: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Primary Objectives• To determine whether metoprolol XL

reduces:- Total mortality- The combined end point of all-cause

mortality and all-cause hospitalizationin patients with HF (NYHA Class II–IV)

Page 29: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Inclusion Criteria• Age 40–80 years• NYHA Class II–IV• Standard treatment for HF for at least 2 weeks

before randomization• EF 35%, or 36% to 40% with a 6-minute

walk test 450 meters

• Resting heart rate 68 bpm• Supine systolic BP 100 mm Hg

Page 30: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Study Design

*The recommended starting dose was 12.5 mg of blind medicine in patients with NYHA Class III–IV heart failure and 25 mg in Class II heart failure.

Single-blind Double-blind

Months

n=2001

n=1990

Titrated from12.5 mg/25 mg

to 200 mgonce daily*

Placebo

MetoprololXL

211812 159612246802

PlaceboRun-in

Weeks

Page 31: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Mean Dose at Study Closure

0

40

80

120

160

200

Mea

n do

se (m

g)179 mg

159 mg

Placebo Metoprolol XL

Page 32: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?
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Page 34: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?
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Combination Beta and Alpha

AntagonistsCarvedilol

Page 37: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Adapted from Packer et al, NEJM, 1996.

Placebo (n=398)Carvedilol (n=696)

Days

Risk reduction=65% P<.001

Survival1.0

0.9

0.8

0.7

0.6

00 100 200 300 400 Progressive

HFSudden cardiac

death

Patients(%)

3.8†

3.3

0.7

1.7

4

3

2

1

0

P=.001†P<.05

Mortality in US Carvedilol Heart Failure Program

Page 38: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

COPERNICUS: Major questions• Can the sickest (class IV) CHF

patients be safely and effectively treated with carvedilol?

• Can carvedilol therapy be initiated during the hospitalization for CHF?

Page 39: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

COPERNICUS: Study design• 2289 patients enrolled

• Incusion criteria- Ischemic or non-ischemic cardiomyopathy- Severe (Class III-IV) CHF- LVEF <25%

• Exclusion- Allergic to carvedilol- Already on beta blocker therapy- Fluid over-load- On IV inotropes

Page 40: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

COPERNICUS: High-Risk Subgroup

• Hospitalised at time of randomisation

• Hospitalised 3 times or more for CHF within last year

• LV ejection fraction < 15%

• Fluid retention (ascites, rales or oedema)

• Required IV positive inotropic agent or vasodilator within last 2 weeks

Packer M et al. N Engl J Med 2001

Page 41: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

COPERNICUS: Study course• Patients stabilized with diuretics and ACE

inhibitor therapy• Patients may be given digoxin and

amiodarone but not required• Patients slowly titrated with carvedilol

therapy as tolerated- Start with 3.125 mg po bid- Initial titration often performed while in the

hospital- Up-titrate dose about every two weeks- Patients followed for 2 years

Page 42: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

% S

urvi

val

% S

urvi

val

0000

33 66 99 1212 1515 1818 2121MonthsMonths

100100

9090

8080

6060

7070

P = 0.00013P = 0.00013

CarvedilolCarvedilol

PlaceboPlacebo

COPERNICUS: All-Cause Mortality

Page 43: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

COPERNICUS: Effect During First 8 Weeks

Krum H et al. JACC 2002Krum H et al. JACC 2002

Death, Hospitalization and Permanent WithdrawalDeath, Hospitalization and Permanent Withdrawal

CarvedilolCarvedilol

0000 22 44 66 88

% P

atie

nts

with

eve

nt%

Pat

ient

s w

ith e

vent

2020

1010

55

1515PlaceboPlacebo

Weeks After RandomizationWeeks After Randomization

Page 44: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

COPERNICUS: Effect During First 8 Weeks

PlaceboPlacebo

CarvedilolCarvedilol

3030

2020

1010

0000 22 44 66 88

% P

atie

nts

with

eve

nt%

Pat

ient

s w

ith e

vent

Death, Hospitalization and Withdrawal inDeath, Hospitalization and Withdrawal inHighest Risk PatientsHighest Risk Patients

Weeks After RandomizationWeeks After Randomization

Page 45: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Reasons Given for Not Using -Blockers

in Patients With Severe Heart Failure:

All proven wrong by COPERNICUS

• Lack of appreciation for disease process- My patient has terminal disease. There is nothing I can do to help

him / her

• Misunderstanding about efficacy - I can accomplish what I need to do with other CHF drugs without

having to use a -blocker

• Excessive concern about safety - My patient is too unstable for a -blocker. It would be best to delay

treatment for a while until he / she is more stable

Page 46: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

COPERNICUS: Conclusions• This study demonstrates that, even in

the most sick CHF patients, carvedilol therapy results in significant clinical benefit.

• Also, this life-saving therapy can be initiated very early after volume stabilization, often-times even during initial hospitalization.

Page 47: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Carvedilol or Metoprolol in Heart Failure: Which is Best?

Page 48: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?
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Beta Blockers in CAD• Beta blockers are good for post-MI

• Beta blockers are good for CHF• What about run-of-mill CAD?

- Beta blockers are good anti-anginal agents• But do they save lives?

- No randomized trials- Without data, national guidelines recommend it for

USA

Page 59: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

LDS Hospital Study• 4,304 patients with angiographically-confirmed coronary

artery disease- No history of CHF- No history of MI

• Data recorded included baseline demographics, socioeconomic status, cardiac risk factors, clinical presentation, therapeutic procedures.

• Certain cardiac medications including beta-blockers which were prescribed at discharge were recorded

• Patients were followed for an average of 3±1.9 years for outcomes of all-cause death and myocardial infarction.

AHA, 2002

Page 60: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

0

5

10

15

20

Death MI Death/MI

No Beta-blocker Beta-blocker

Perc

ent

Univariate Effect of Beta-Blockade on Death, MI, and Death/MI

Page 61: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?
Page 62: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

LDS Hospital Study: Conclusions• Prescription of beta-blockers at hospital

discharge seems protective against all-cause death for patients with coronary artery disease even if they do not have history of heart failure or myocardial infarction.

• Prescription of beta-blockers in these patients does not appear protective against future myocardial infarction.

Page 63: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Beta Blockers in Hypertension

Page 64: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Atenolol Versus Placebo Meta-analysis

Page 65: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Atenolol versus otherAntihypertensive agents:

Meta-analysis

Page 66: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Recent Guidelines Changes Regarding Beta Blockers and

Hypertension• In early versions of JNC, beta-blockers were

considered first-line therapy.• But in JNC 7, beta-blockers were considered only

either as add-on therapy to thiazide-type diuretics, or as initial therapy in patients with compelling other indications.

• Recent European hypertension guidelines have relegated beta-blockers to fourth-line agents, after diuretics, RAAS blockers, and CCBs in patients with uncomplicated hypertension.

Page 67: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Beta Blockers in Non-Cardiac Surgery• General anesthesia produces

significant sympathetic responses.• Peri-operative MI is significant in older

patients undergoing non-cardiac surgery

• Beta blockade may be helpful

Page 68: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Peri-operative Beta Blockers in Non-

cardiac Surgery Study • 200 elderly patients undergoing non-cardiac surgery

• Randomized to atenolol versus placebo• Followed for up to two years• Death• Peri-operative MI

NEJM 1996

Page 69: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Peri-operative Beta Blockers

Page 70: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Peri-operative Beta Blockers

Page 71: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Peri-operative Beta Blockers

Page 72: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

2007 National Guidelines

Page 73: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?
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Revised Meta-analysis

• Conclusions: - Guideline bodies should retract their recommendations based on fictitious

data without further delay. - The well-conducted trials indicate a statistically significant 27% increase in

mortality from the initiation of perioperative β-blockade that guidelines currently recommend.

Page 86: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Perioperative Beta Blocker Therapy:

Brent’s Opinion• If patients are already on beta blocker therapy, leave them on it through the entire perioperative period.

• If they are not, then probably leave them that way.

• We hoped beta blockers would help, and indeed they do prevent heart attacks, but unfortunately they also increase the risk of strokes and death.

Page 87: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Miscellaneous Other Uses of Beta Blockers for

Cardiovascular Patients• Rate control for atrial fibrillation• Prevention of supraventricular tachycardia• Treatment of inappropriate sinus

tachycardia• Treatment and prevention of non-

sustained ventricular tachycardia• Treatment of thyroid storm associated

hypertension and tachycardia

Page 88: Beta Blockers Treatment  For Cardiovascular  Disease Where  Do They Fit ?

Conclusions• Beta blocker therapy continues to be a

very important strategy in the management of a wide variety of cardiovascular patients

• It remains one of a very few agents that has actually been shown to save lives.

• The major change from the past is that beta blockers are now lower priority for the primary treatment of hypertension.


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