Nebivolol for the Treatment of Essential Systemic Arterial Hypertension: A Systematic Review and Meta-Analysis.

INTRODUCTION: Cardiovascular diseases are the main cause of mortality worldwide, and systemic arterial hypertension is associated with a large number of these cases. The objective of health professionals and health policies should be searching for the best therapeutics to control this disease. A recent consensus indicated that ß-blockers have recently lost their place in initial indications for the treatment of systemic arterial hypertension and are now more indicated for the treatment of hypertension in association with other clinical situations such as angina, heart failure and arrhythmia; however, it is known that this approach was based on studies that evaluated older ß-blockers such as atenolol. OBJECTIVE: The main objective of this study was to perform a systematic review with subsequent meta-analysis on the use of nebivolol for hypertensive disease treatment, comparing it with drugs of the main antihypertensive classes. METHODS: This systematic review was based on a search of the MEDLINE (via Pubmed), Scopus, Cochrane, International Pharmaceuticals Abstracts (IPA), and Lilacs databases for randomized and double-blind clinical trials. In addition, we also searched for gray literature studies, to 31 July 2015. Next, a cumulative meta-analysis was performed, with studies being added in a sequential manner, evaluating their impact on the combined effect. For this project, we only meta-analyzed direct comparisons of random effect. RESULTS: Overall, 981 clinical trials were included in this systematic review. After careful analysis, 34 randomized and double-blind clinical trials were included to investigate the efficacy of nebivolol on systolic (SBP) and diastolic blood pressure (DBP) control and adverse effects. The study population comprised 12,465 patients with systemic arterial hypertension (SAH) aged between 18 and 85 years; 17% of subjects were of Black ethnicity, approximately 55% were men, and almost 10% had diabetes. In SBP management, nebivolol was superior to other ß-blockers and diuretics and showed no difference in efficacy when compared with angiotensin receptor blockers or calcium channel blockers. There were insufficient studies on angiotensin-converting enzyme inhibitors for adequate comparison of both SBP and DBP control. For DBP control, nebivolol was more efficient than other ß-blockers, angiotensin receptor blockers, diuretics, and calcium channel blockers. DISCUSSION: Nebivolol is a third-generation ß-blocker with additional capabilities to improve blood pressure levels in patients with arterial hypertension, because it acts by additional mechanisms such as endothelium-dependent vasodilation associated with L-arginine and oxide nitric acid, nitric oxide activity on smooth muscle cells, decreasing platelet aggregation, and leukocyte adhesion in the endothelium, decreasing oxidative stress. Although nebivolol has shown good results in controlling hypertension in this study (with few adverse events when compared with placebo treatment) and has an unquestionable benefit in individuals with heart failure (mainly with reduced ejection fraction), there is a lack of studies proving the benefit of this drug for controlling hypertension and reducing clinical outcomes such as cardiovascular (or general) mortality, acute myocardial infarction, or stroke. CONCLUSIONS: Nebivolol demonstrated at least similar control of blood pressure levels in hypertensive individuals when compared with drugs of the most used classes. In addition, in relation to the control of arterial hypertension, studies with clinical outcomes should be performed to ensure the use of this drug in detriment to others with these well-established results.

Outcome of patients with high-risk Duke treadmill score and normal myocardial perfusion imaging on spect.

BACKGROUND: Annual mortality rate can range from <1% for patients with normal myocardial perfusion by SPECT to >5% based on a high-risk Duke treadmill score (DTS). Information on the prognosis of patients with the combination of HRDTS and normal SPECT is limited and is the purpose of this study. METHODS: Data from a large nuclear cardiology registry (n = 17,972 patients) were reviewed. A total of 340 had HRDTS (score ≤ -11) while undergoing SPECT. Combined cardiovascular mortality and non-fatal myocardial infarction (MI) and cardiovascular mortality alone were available in 310 patients at a mean follow-up of 4.01 ± 1.5 years. RESULTS: The majority of the patients had abnormal SPECT (n = 270, 71%). The abnormal SPECT patients compared to the normal were older (65.6 vs 62.8 years of age; P = .025), more likely to have abnormal left ventricular ejection fraction (26.1% vs 0%; P < .0001), known coronary artery disease (CAD, 35.9% vs 7.8%; P < .0001) and lower DTS (-14.5 vs -13.2; P = .0006), Kaplan-Meier survival analysis demonstrated a significantly lower cardiovascular mortality (5.4% vs 0%, P = .02) and combined outcome of MI and cardiovascular mortality (15% vs 4.4%, P = .009) in patients with normal versus abnormal SPECT. CONCLUSIONS: High-risk DTS is associated with abnormal perfusion SPECT in most patients, but nearly one-third of the patients had normal perfusion. Patients with a normal SPECT had a lower cardiovascular event rates.

Myocardial perfusion imaging is a strong predictor of death in women.

OBJECTIVES: We sought to assess the prognostic value and risk classification improvement using contemporary single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) to predict all-cause mortality. BACKGROUND: Myocardial perfusion is a strong estimator of prognosis. Evidence published to date has not established the added prognostic value of SPECT-MPI nor defined an approach to detect improve classification of risk in women from a developing nation. METHODS: A total of 2,225 women referred for SPECT-MPI were followed by a mean period of 3.7 ± 1.4 years. SPECT-MPI results were classified as abnormal on the presence of any perfusion defect. Abnormal scans were further classified as with mild/moderate reversible, severe reversible, partial reversible, or fixed perfusion defects. Risk estimates for incident mortality were categorized as <1%/year, 1% to 2%/year, and >2%/year using Cox proportional hazard models. Risk-adjusted models incorporated clinical risk factors, left ventricular ejection fraction (LVEF), and perfusion variables. RESULTS: All-cause death occurred in 139 patients. SPECT-MPI significantly risk stratified the population; patients with abnormal scans had significantly higher death rates compared with patients with normal scans, 13.1% versus 4.0%, respectively (p < 0.001). Cox analysis demonstrated that after adjusting for clinical risk factors and LVEF, SPECT-MPI improved the model discrimination (integrated discrimination index = 0.009; p = 0.02), added significant incremental prognostic information (global chi-square increased from 87.7 to 127.1; p < 0.0001), and improved risk prediction (net reclassification improvement = 0.12; p = 0.005). CONCLUSIONS: SPECT-MPI added significant incremental prognostic information to clinical and left ventricular functional variables while enhancing the ability to classify this Brazilian female population into low- and high-risk categories of all-cause mortality.

[Radiofrequency catheter ablation of left accessory pathways by transeptal approach]. / Ablação por cateter com radiofreqüência de vias acessórias esquerdas por abordagem transeptal.

OBJECTIVE: To study a series of patients submitted to radiofrequency catheter ablation (RFA) of left accessory pathways (AP) using the transeptal approach (TSA) as compared to the conventional retrograde arterial approach (RAA). METHODS: One hundred consecutive patients (56 male; mean age of 34.3 +/- 11 years) with 100 left APs (62 overt and 38 concealed) underwent catheter ablation using the TS method (50 patients) and the RA method (50 patients) in an alternate fashion. The analysis was performed according to the intention-to-treat principle. RESULTS: The transeptal puncture was successfully performed in 48 patients (96%). This access allowed primary success in the ablation in all the patients without any complication. When we compared this approach with the RAA there was no difference as regards the primary success (p = 0.2), recurrence rate (p = 1.0), fluoroscopy time (p = 0.63) and total time (p = 0.47). One patient in the RAA group presented a vascular complication. The TSA allowed shorter ablation times (p=0.01) and smaller number of radiofrequency applications (p = 0.003) as compared to the conventional RAA. The patients who had recurrence and unsuccessful ablation in the first session in each approach underwent another session with the opposite technique (cross-over), with a final ablation success rate of 100%. CONCLUSION: The TS and RA approaches showed similar efficacy and safety for the ablation of left accessory pathways. The TSA allowed shorter ablation times and smaller number of radiofrequency applications. When the techniques were used in a complementary fashion, they increased the final efficacy of the ablation.

Evolutive echocardiographic study of the structural and functional heart alterations in obese individuals after bariatric surgery.

OBJECTIVE: To evaluate with Doppler echocardiography the reversibility of structural and hemodynamic changes in obeses after bariatric surgery. METHODS: Twenty-three patients (19 women = 82.6%) were studied. Mean age was 37.9 years. All subjects had Class III or Class II obesity with comorbidity and were submitted to bariatric surgery. Clinical and echocardiographic evaluation were performed preoperatively, in 6 months and 3 years after surgery. RESULTS: Preoperatively, the mean weight and blood pressure (BP) were respectively 128.7 +/- 25.8 kg and 142.2 +/- 16.2 / 92.2 +/- 10.4 mmHg. Postoperatively, they showed important body weight reduction in 6 months (97.6 +/- 18.3 kg) and 3 years (83.6 +/- 13.5 kg), and BP reduction in 6 months (128.5 +/- 16.1/80.7 +/- 9.9 mmHg) that remain stable in 3rd year. On echocardiogram, preoperatively, there was hypertrophy of the septum and posterior wall associated with normal diastolic dimension; the predominant LV geometric pattern was concentric remodeling (74%). At six months, thinning of the ventricular septum and LV posterior wall, and increase in LV diastolic dimension were demonstrated. At 3rd year, the predominant LV pattern was normal (69%), with reduction of LV mass and LV mass/height2 index. We noticed improved diastolic function, with an increased E/A ratio and a decreased LV isovolumic relaxation time. The Myocardial Performance Index was obtained retrospectively in 13 patients and improved in 6 months. There was an increase of the ejection time in 6 months and an elevation of the ejection fraction in 3rd year, suggesting improvement of the LV systolic function. CONCLUSION: The weight loss obtained with bariatric surgery promotes both structural and functional myocardial changes that improve cardiac performance.