Associations between ß-blockers and psychiatric and behavioural outcomes: A population-based cohort study of 1.4 million individuals in Sweden.

BACKGROUND: ß-blockers are widely used for treating cardiac conditions and are suggested for the treatment of anxiety and aggression, although research is conflicting and limited by methodological problems. In addition, ß-blockers have been associated with precipitating other psychiatric disorders and suicidal behaviour, but findings are mixed. We aimed to examine associations between ß-blockers and psychiatric and behavioural outcomes in a large population-based cohort in Sweden. METHODS AND FINDINGS: We conducted a population-based longitudinal cohort study using Swedish nationwide high-quality healthcare, mortality, and crime registers. We included 1,400,766 individuals aged 15 years or older who had collected ß-blocker prescriptions and followed them for 8 years between 2006 and 2013. We linked register data on dispensed ß-blocker prescriptions with main outcomes, hospitalisations for psychiatric disorders (not including self-injurious behaviour or suicide attempts), suicidal behaviour (including deaths from suicide), and charges of violent crime. We applied within-individual Cox proportional hazards regression to compare periods on treatment with periods off treatment within each individual in order to reduce possible confounding by indication, as this model inherently adjusts for all stable confounders (e.g., genetics and health history). We also adjusted for age as a time-varying covariate. In further analyses, we adjusted by stated indications, prevalent users, cardiac severity, psychiatric and crime history, individual ß-blockers, ß-blocker selectivity and solubility, and use of other medications. In the cohort, 86.8% (n = 1,215,247) were 50 years and over, and 52.2% (n = 731,322) were women. During the study period, 6.9% (n = 96,801) of the ß-blocker users were hospitalised for a psychiatric disorder, 0.7% (n = 9,960) presented with suicidal behaviour, and 0.7% (n = 9,405) were charged with a violent crime. There was heterogeneity in the direction of results; within-individual analyses showed that periods of ß-blocker treatment were associated with reduced hazards of psychiatric hospitalisations (hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.91 to 0.93, p < 0.001), charges of violent crime (HR: 0.87, 95% CI: 0.81 to 0.93, p < 0.001), and increased hazards of suicidal behaviour (HR: 1.08, 95% CI: 1.02 to 1.15, p = 0.012). After stratifying by diagnosis, reduced associations with psychiatric hospitalisations during ß-blocker treatment were mainly driven by lower hospitalisation rates due to depressive (HR: 0.92, 95% CI: 0.89 to 0.96, p < 0.001) and psychotic disorders (HR: 0.89, 95% CI: 0.85 to 0.93, p < 0.001). Reduced associations with violent charges remained in most sensitivity analyses, while associations with psychiatric hospitalisations and suicidal behaviour were inconsistent. Limitations include that the within-individual model does not account for confounders that could change during treatment, unless measured and adjusted for in the model. CONCLUSIONS: In this population-wide study, we found no consistent links between ß-blockers and psychiatric outcomes. However, ß-blockers were associated with reductions in violence, which remained in sensitivity analyses. The use of ß-blockers to manage aggression and violence could be investigated further.

Severe cardiac failure due to rapidly progressive rheumatoid arthritis-associated valvulopathy.

Cardiac failure due to rapidly progressive valve disease is a rare complication of rheumatoid arthritis (RA) that can be challenging to manage. A patient with severe heart failure secondary to RA who, after failing to respond to medical therapy, underwent high-risk valve surgery and did remarkably well, with dramatic symptomatic improvement and essentially normalised left ventricular size and function as seen on follow-up echocardiography.

Variable presentation of ventricular tachycardia-like electrocardiographic artifacts.

Diagnosis of clinically significant ventricular tachycardia (VT) relies on accurate electrocardiogram (ECG) interpretation, in the context of a convincing clinical picture. ECG artifacts resembling VT are common and can be misleading. We present two instances of VT-like ECG artifacts, which demonstrate the variable presentation of such artifacts and highlight ways in which these ECG tracings can be distinguished from true VT.

Ankle brachial pressure index (ABPI): An update for practitioners.

Peripheral vascular disease affects some 12%-14% of the general population, and the majority of people with the disease are asymptomatic. The ankle brachial pressure index (ABPI) test is widely used by a diverse range of practitioners (in the community and hospital setting) in order to screen asymptomatic patients, diagnose patients with clinical symptoms, and to monitor patients who have had radiological or surgical intervention. This paper explains the theoretical basis of the ABPI test, as well as the relevance of the common modifications of the test. It explores the background to the quoted normal ranges for the ABPI test. It reviews the large body of literature that has developed on the association between ABPI and cardiovascular risk, as well as ABPI as a predictor for cardiovascular morbidity and mortality, highlighting the evidence that can inform practice. The review looks critically at the limitations of the ABPI test, providing practitioners with an evidence-based update on the importance and challenges of standardizing ABPI methodology. This paper highlights the influence of the key technical aspects of the ABPI test that all practitioners need to consider in order to be able to make more reliable and informed management decisions based on ABPI findings.

Haemodynamic significance of an anomalous right coronary with inter-arterial course assessed with intracoronary pressure measurements during dobutamine challenge.

Autopsy studies have associated congenital coronary anomalies with the risk of sudden cardiac death. However, not all patients with anomalous coronary arteries die suddenly. A means of assessing the potential for ischaemia and thus predicting the risk of sudden death in these patients may be necessary for directing treatment. We present the case of a patient with an anomalous right coronary artery originating from the aortic wall above the left sinus of Valsalva, with an anterior inter-arterial course. The haemodynamic significance of this anomaly was assessed using intracoronary pressure-wire measurements at rest and during dobutamine stress. This technique could be a valid means for assessing stress-induced ischaemia and, therefore, by inference, the risk of sudden cardiac death in these patients.