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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
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
Time (years)
No Symptoms ± Symptoms Symptoms
• Ischemic HeartDisease
• CerebrovascularDisease
• PeripheralVascularDisease
Schematic Timecourseof Human Atherogenesis
Pathogenesis of ACS
White HD. Am J Cardiol. 1997; 80(4A):2B-10B.
The matrix skeleton of an unstablecoronary artery plaque
fissures inthe fibrous cap
Plaque rupture with thrombosisPlaque rupture with thrombosis
1 mm FJ Schoen, BWH
Thrombus Fibrous cap
Lipid coreLipid core
Plaque rupture
site
fatal thrombus
collagenous fibrous cap
thrombogenic lipid core
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
Beta Blockers: 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
Beta Blockers: Indications• Post MI
• CAD• Heart Failure• Hypertension• Non-cardiac surgery• Rate Control
- Atrial fibrillation- Inappropriate sinus tachycardia
• Arrhythmias
Beta Blockers Post-MI• Rationale
- Antiplatelet effect- Antiarrhthmic effect- General blood pressure effect
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
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
Effect on sudden death of beta blockade following MI. Pooled data
from 5 trials
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
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
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
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)
Beta Blockers in Heart Failure
Vicious Cycle of Heart Failure
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
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
Death or Transplant
Change In Ejection Fraction
Change in Functional Status
Study Results
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)
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
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
Mean Dose at Study Closure
0
40
80
120
160
200
Mea
n do
se (m
g)179 mg
159 mg
Placebo Metoprolol XL
Combination Beta and Alpha
AntagonistsCarvedilol
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
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?
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
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
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
% 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
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
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
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
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.
Carvedilol or Metoprolol in Heart Failure: Which is Best?
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
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
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
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.
Beta Blockers in Hypertension
Atenolol Versus Placebo Meta-analysis
Atenolol versus otherAntihypertensive agents:
Meta-analysis
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.
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
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
Peri-operative Beta Blockers
Peri-operative Beta Blockers
Peri-operative Beta Blockers
2007 National Guidelines
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.
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.
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
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.