英文精品课件bblockerin patients with coexistent hf and reactive airway

b-blocker in patients with coexistent HF and reactive airway disease Background Beta blockers are recommended for the treatment of all patients (in NYHA class II-IV) with stable, mild, moderate, and severe HF from ischaemic or non-ischaemic cardiomyopathies and reduced LVEF on standard treatment, including diuretics and ACEI, unless there is a contraindication. (evidence class IA) Beta blockers therapy reduce hospitalizations (all, CV and HF), improves the functional class and leads to less worsening of HF. (Reduction all-cause mortality) (evidence class IA) ESC guideline for CHF; 2005. The patient should be in a relatively stable condition, without the need of intravenous inotropic therapy and without signs of marked fluid retention. Differences in clinical effects may be present between different beta-blockers in patients with HF. Only bisoprolol, carvedilol, metoprolol succinate, and nebivolol can be recommended. (evidence class IA) ESC guideline for CHF; 2005. Background Contraindications to beta-blockers Asthma bronchiale Severe bronchial disease (ex: COPD) Symptomatic bradycardia or hypotension Background ESC guideline for CHF; 2005. P.I.C.O. Patients (P) Intervention (I) Comparison (C) Outcome (O) HF with airway disease beta-blockersPlacebo FEV1 change Pt symptom Mortality Database Search Cochrane Library key word: heart failure and airway disease and beta-blocker Found: 2/9 related results * Cardioselective beta-blockers for chronic obstructive pulmonary disease. * Cardioselective beta-blockers for reversible airway disease. Database Search Bandolier key word: heart failure, airway disease, COPD, beta-blocker Found: No related result Database Search ACP Journal Club key word: heart failure, airway disease, COPD, beta-blocker Found: No related result Database Search EMBASE- Drugs Keogh, Anne M.a; Macdonald, Peter S.a; Arnold, Ruth H.a; McCaffrey, Dermot J.a; Glanville, Allan R.a J Heart Lung Transplant 2002; 21: 1290-1295. Background Little information exists on the tolerability of carvedilol in patients with chronic obstructive pulmonary disease (COPD). In this study, we assessed the tolerability and efficacy of carvedilol in patients with CHF and concomitant COPD or asthma. Methods Between 1996 and 2000, a total of 487 patients began receiving open-label carvedilol. 43 (9%) had COPD (n = 31) or asthma (n = 12). 60% began carvedilol therapy in the hospital and underwent measurement of peak expiratory flow rates (PEFR) before and after dosing. Patients were observed for a mean of 2.4 years. 17% increase (p=0.04) in PEFR in patients with COPD and a non-significant increase of 4% in patients with asthma (p=0.29). J Heart Lung Transplant 2002; 21: 1290-1295. Result J Heart Lung Transplant 2002; 21: 1290-1295. 1 patient (3.2%) was withdrawn from carvedilol therapy because of an exacerbation of the pulmonary disease. Four other patients (12.9%), intolerant of carvedilol, ceased therapy because of worsening heart failure. J Heart Lung Transplant 2002; 21: 1290-1295. In patients who tolerated carvedilol, echocardiography at 12 months demonstrated a statistically improvement in LV dimensions and function accompanied by improvement in NYHA functional class in 68%. CONCLUSION 1.Patients with CHF and COPD tolerated carvedilol well with no significant reversible airflow limitation, but patients with CHF and asthma tolerated carvedilol poorly. 2.The effect of carvedilol on LV dimensions and function in patients with concomitant airway diseases was similar to that seen in our general group of patients. 3.Asthma remains a contraindication to b-blockade. J Heart Lung Transplant 2002; 21: 1290-1295. Selective beta-1-adrenergic blockade is routinely preferred to non-selective blockade in patients with coexistent COPD and CHF to minimize the risk of inducing bronchoconstriction. Recent limited evidence indicates that combined non-selective beta- and alpha-adrenergic blockade is well tolerated by patients with COPD who do not have reversible airway obstruction. Alpha-1-adrenergic-blocking agents such as phentolamine and indoramine produce mild bronchodilation in patients with obstructive airway disease and abolish propranolol- induced bronchoconstriction. Alpha -1-blocking activity of carvedilol and labetalol may be sufficient to offset beta-adrenergic blockade-induced bronchoconstriction in patients with COPD, but not in patients with asthma. JACC 2004; 44(3): 497-502. Selective beta-1-blockade or non-selective beta- combined with alpha-adrenergic blockade should not be withheld in patients with CHF and COPD without reversible airway obstruction. In patients with CHF and COPD with reversible airway obstruction, selective beta-1-blockade remains the preferred approach in the absence of safety data on agents combining non- selective beta- with alpha-adrenergic blockade. Selective beta-1-blockade and non-selective beta- combined with alpha-adrenergic blockade should be avoided during COPD exacerbation until safety data are available. JACC 2004; 44(3): 497-502. 總 結 Cardioselective-nonISA beta-blocker agent (Atenolol, Bisoprolol, Metoprolol, Practolol) for reversible airway disease Total reversible airway ds pt FEV1 Sub: COPD FEV1 Sub: CVD FEV1 Pt symptom併beta- agonist FEV1 Single dose (v.s placebo) WMD 9.14 -11.31, -6.97 P 0.00001 WMD 5.28 -10.03, -0.54 P=0.03 WMD 6.83 -11.46, -2.20 P=0.004 No significant RD 0.00 -0.03, 0.03; p= 1 WMD 6.59 4.18, 9.01 P 0.00001 Longer duration (v.s placebo) No significant WMD 3.22 7.79, 1.36; p= 0.2 No significant WMD 6.20 -16.37, 3.97; p= 0.2 No significant WMD 1.40 -8.10, 5.31; p= 0.7 No significant RD 0.01 -0.02, 0.04; p=0.5 WMD 12.0 4.12, 19.87 P 0.003 RD: Risk difference WMD: Weighted Mean Difference 總 結 Cardioselective beta-blocker agent (Atenolol, Bisoprolol, Metoprolol, Practolol, Celiprolol) for COPD Total COPD pt FEV1 Pt symptom Severe COPD FEV1 Reversible ai rway disease FEV1 CVD FEV1 併beta- agonist FEV1 Single dose (v.s placebo) WMD 2.08 -5.25, 1.09 P= 0.2 WMD 0.00 -0.04, 0.04 P= 1 WMD 0.71 -5.69, 4.27 P= 0.8 WMD 1.8 -7.01, 3.41 P= 0.5 W