Initiation or maintenance of beta-blocker therapy in patients hospitalized for acute heart failure.

Background Beta-blockers have been recommended for patients with heart failure and reduced ejection fraction for their long-term benefits. However, the tolerance to betablockers in patients hospitalized with acute heart failure should be evaluated. Objective To estimate the proportion of patients hospitalized with acute heart failure who can tolerate these agents in clinical practice and compare the clinical outcomes of patients who can and cannot tolerate treatment with beta-blockers. Setting Two reference hospitals in cardiology. Methods Retrospective cohort study of consecutive patients hospitalized for acute heart failure between September 2008 and May 2012. Population-based sample. During the study period, 325 patients were admitted consecutively, including 194 individuals with an acute heart failure diagnosis and systolic left ventricular dysfunction and ejection fraction ≤45 %, who were candidates for the initiation or continuation of beta-blockers. Main outcome measure The percentage of patients intolerant to beta-blockers and the clinical characteristics of patients. Results On admission, 61.8 % of patients were already using beta-blockers, and 73.2 % were using beta-blockers on discharge. During hospitalization, 85 % of patients used these agents for some period. The main reasons for not using betablockers were low cardiac output syndrome (24.4 %), bradycardia (24.4 %), severe hypotension or shock (17.8 %), and chronic obstructive pulmonary disease (13.3 %). Patients who were intolerant or did not use a beta-blocker had a longer hospital stay (18.3 vs. 11.0 days; p < .001), greater use of vasoactive drugs (41.5 vs. 16.3 %; p < .001, CI 1.80-7.35), sepsis and septic shock (RR = 3.02; CI 95 % 1.59-5.75), and higher mortality rate during hospitalization (22.6 vs. 2.9 %; p < .001; CI 3.05-32.26). Conclusion Beta-blockers could be used in 73.2 % of patients hospitalized for acute heart failure. Patients who can not tolerate BB presented a higher frequency of adverse clinical outcomes including frequency of sepsis, use of vasoactive drugs, average length of hospitalization, and death.

Is there evidence favoring the use of beta-blockers and dobutamine in acute heart failure?

Several studies have reported the benefits of beta-blockers (BB) for patients presenting with systolic heart failure. however, many patients hospitalized as a result of acute heart failure are already using BB and require dobutamine for arterial hypotension and low cardiac output. Therefore, a decision must be made regarding whether BB should be maintained or even started in such cases. The aim of this study was to establish whether there is evidence supporting the safety andyeffectiveness of BB together with dobutamine for patients presenting with acute decompensated heart failure (ADHF). We conducted a search of the English-language literature in the databases MEDLINE, ISI Web of Science, Virtual Health Library, Cochrane Library and the CAPES Portal of Scientific Journals to identify related studies. Additional literature was obtained through the review of relevant references in the identified articles. The expected outcomes included information on the prognosis (in-hospital and on follow-up mortality, number of days of hospitalization and readmission),yeffectiveness and safety (worsening of symptoms, shock, intolerance) of the concomitant use of these drugs in hospitalized patients with ADHF and low cardiac output. This review included nine studies. however, no randomized clinical trials on this subject were found. Most studies include a low number of patients, and no studies addressing the safety of the concomitant use of these drugs were found. The resulting data suggest that a careful literature review did not supply evidence for the systematic use of BB in patients with low cardiac output syndrome who require dobutamine for inotropic support.

Há evidências favorecendo o uso de betabloqueadores e dobutamina na insuficiência cardíaca aguda? / Is there evidence favoring the use of beta-blockers and dobutamine in acute heart failure?

Diversos estudos relataram os benefícios dos betabloqueadores (BB) para pacientes com insuficiência cardíaca sistólica. No entanto, muitos pacientes hospitalizados em decorrência de insuficiência cardíaca aguda já estão usando os BB e requerem dobutaminas para hipotensão arterial e baixo débito cardíaco. Portanto, deve-se tomar uma decisão a respeito de se o BB deve ser mantido ou até mesmo iniciado nesses casos. O objetivo deste estudo foi determinar se há provas que sustentem a segurança e a eficácia dos BB junto com a dobutamina para pacientes com insuficiência cardíaca aguda descompensada (ICAD). Foi realizada uma pesquisa na literatura de língua inglesa nas bases de dados MEDLINE, ISI Web of Science, Biblioteca Virtual em Saúde, Cochrane Library e o Portal de Revistas Científicas do Capes para identificar estudos relacionados. Literatura adicional foi obtida mediante a análise das respectivas referências encontradas nos artigos identificados. Os resultados esperados incluíram informações sobre o prognóstico (intra-hospitalar e na mortalidade no acompanhamento, número de dias de internação e reinternação), eficácia e segurança (agravamento dos sintomas, choque, intolerância) do uso concomitante desses medicamentos em pacientes hospitalizados com ICAD e baixo débito cardíaco. Esta análise incluiu nove estudos. No entanto, não foram encontrados ensaios clínicos randomizados sobre o assunto. A maioria dos estudos inclui baixo número de pacientes, e não foram encontrados estudos que abordem a segurança do uso concomitante desses medicamentos. Os dados resultantes sugerem que uma cuidadosa revisão da literatura não forneceu evidências para o uso sistemático de BB em pacientes com síndrome de baixo débito cardíaco que necessitam de suporte inotrópico com dobutamina.

Several studies have reported the benefits of beta-blockers (BB) for patients presenting with systolic heart failure. however, many patients hospitalized as a result of acute heart failure are already using BB and require dobutamine for arterial hypotension and low cardiac output. Therefore, a decision must be made regarding whether BB should be maintained or even started in such cases. The aim of this study was to establish whether there is evidence supporting the safety andyeffectiveness of BB together with dobutamine for patients presenting with acute decompensated heart failure (ADHF). We conducted a search of the English-language literature in the databases MEDLINE, ISI Web of Science, Virtual Health Library, Cochrane Library and the CAPES Portal of Scientific Journals to identify related studies. Additional literature was obtained through the review of relevant references in the identified articles. The expected outcomes included information on the prognosis (in-hospital and on follow-up mortality, number of days of hospitalization and readmission),yeffectiveness and safety (worsening of symptoms, shock, intolerance) of the concomitant use of these drugs in hospitalized patients with ADHF and low cardiac output. This review included nine studies. however, no randomized clinical trials on this subject were found. Most studies include a low number of patients, and no studies addressing the safety of the concomitant use of these drugs were found. The resulting data suggest that a careful literature review did not supply evidence for the systematic use of BB in patients with low cardiac output syndrome who require dobutamine for inotropic support.

Evaluating the adequacy of cardiovascular risk factor control after myocardial revascularization surgery / Avaliação da adequação do controle de fatores de risco cardiovascular após cirurgia de revascularização miocárdica

FUNDAMENTO: Os fatores de risco cardiovascular (FR) são responsáveis pela ocorrência de eventos cardiovasculares. OBJETIVO: Estimar o porcentual de pacientes submetidos a cirurgia de revascularização miocárdica (RM) que conseguem controle adequado de fatores de risco (FR) modificáveis, pelo menos seis meses após o procedimento. MÉTODOS: O estudo incluiu 88 pacientes, no qual se realizaram análise de prontuários e entrevista clínica, entre seis e 12 meses após a realização de cirurgia de RM em hospital de referência para doenças cardiovasculares, no período de janeiro a dezembro de 2004. RESULTADOS: A média de idade foi 63,1±9,9 anos: 51 (58 por cento) eram do sexo masculino, 86 (97,7 por cento), hipertensos, 38 (43,2 por cento), diabéticos, 85 (96,6 por cento), dislipidêmicos e 10 (11,4 por cento), tabagistas. O controle da hipertensão (PA < 140x90 mmHg) foi atingido em 24,4 por cento dos pacientes. Para o colesterol (colesterol LDL < 100 mg/dl) e para o diabete melito (glicemia < 110), os níveis de controle foram, respectivamente, 30,6 por cento e 31,6 por cento. O uso de anti-hipertensivos, agentes hipoglicemiantes (orais ou insulina) e estatinas, quando indicado, foi, respectivamente, 96,5 por cento, 92,1 por cento, 78,8 por cento. Entretanto, analisando-se a tríade hipertensão, diabete e hipercolesterolemia, apenas 14,8 por cento do total de pacientes apresentavam níveis de pressão arterial, glicemia e colesterol LDL dentro dos limites aceitáveis. CONCLUSÃO: Apesar do uso freqüente de medicações para controle da hipertensão, diabete e hipercolesterolemia, o controle de fatores de risco ainda é realizado de forma insuficiente nos pacientes revascularizados, o que sugere grande potencial para a melhoria da prática clínica.

BACKGROUND: Cardiovascular risk factors (RF) for coronary artery disease (CAD) are responsible for the occurrence of cardiovascular events. OBJECTIVE: To estimate the percentage of patients submitted to myocardial revascularization surgery (MRS) that attains adequate control of modifiable RF at least six months after the surgery. METHODS: Data collection was based on the review of medical records and a clinical interview of 88 patients submitted to MRS between January and December of 2004 at a reference hospital for cardiovascular diseases. The patients were interviewed in the follow-up period, between six and twelve months after the surgical revascularization. RESULTS: Mean age was 63.1 ± 9.9 years; 51 patients (58 percent) were males, 86 (97.7 percent) were hypertensive, 38 (43.2 percent) were diabetic, 85 (96.6 percent) had hypercholesterolemia and 10 (11.4 percent) were smokers. Hypertension control (PA < 140 x 90 mmHg) was attained by 24.4 percent of the patients; cholesterol (LDL cholesterol < 100 mg/dl) and diabetes control (blood glucose levels < 110 mg/dl) levels were 30.6 percent and 31.6 percent, respectively. The use of antihypertensive drugs, hypoglycemic agents and statins, when indicated, were 96.5 percent, 92.1 percent and 78.8 percent, respectively. However, only 14.8 percent patients had their blood pressure, glucose and cholesterol levels within the limits accepted as adequate control. CONCLUSION: Despite the frequent use of drugs to control hypertension, diabetes and hypercholesterolemia, a high proportion of patients still do not achieve the target levels of risk factor control recommended by current guidelines at least six months after revascularization surgery, which suggests there is a great potential for improvement in clinical practice.

Evaluating the adequacy of cardiovascular risk factor control after myocardial revascularization surgery.

BACKGROUND: Cardiovascular risk factors (RF) for coronary artery disease (CAD) are responsible for the occurrence of cardiovascular events. OBJECTIVE: To estimate the percentage of patients submitted to myocardial revascularization surgery (MRS) that attains adequate control of modifiable RF at least six months after the surgery. METHODS: Data collection was based on the review of medical records and a clinical interview of 88 patients submitted to MRS between January and December of 2004 at a reference hospital for cardiovascular diseases. The patients were interviewed in the follow-up period, between six and twelve months after the surgical revascularization. RESULTS: Mean age was 63.1 +/- 9.9 years; 51 patients (58%) were males, 86 (97.7%) were hypertensive, 38 (43.2%) were diabetic, 85 (96.6%) had hypercholesterolemia and 10 (11.4%) were smokers. Hypertension control (PA < 140 x 90 mmHg) was attained by 24.4% of the patients; cholesterol (LDL cholesterol < 100 mg/dl) and diabetes control (blood glucose levels < 110 mg/dl) levels were 30.6% and 31.6%, respectively. The use of antihypertensive drugs, hypoglycemic agents and statins, when indicated, were 96.5%, 92.1% and 78.8%, respectively. However, only 14.8% patients had their blood pressure, glucose and cholesterol levels within the limits accepted as adequate control. CONCLUSION: Despite the frequent use of drugs to control hypertension, diabetes and hypercholesterolemia, a high proportion of patients still do not achieve the target levels of risk factor control recommended by current guidelines at least six months after revascularization surgery, which suggests there is a great potential for improvement in clinical practice.