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BETABLOCKERS IN CURRENT
CARDIOVASCULAR PRACTICE
Dr. Nagula Praveen, MD, DM
Assistant Professor of Cardiology,
Osmania General Hospital, Hyderabad
Email: drpraveennagula@gmail.com
Twitter: @kizashipraveen
Case 1
 A young male,cocaine addictive to be given BB or not?
 A young patient with angina,BP 170/100 mm Hg on NTG persistnet
chest pain.what to be given?
 BB
 A patient with HF came with acute decompesnation ,basal crepts
 Bb to be continued?
Beta Blockers in current cardiovascular practice
Contents
 Introduction
 Beta Receptors
 Indications for usage of BBs
 Myths vs facts
 Words of caution
 Side effects
 BISOPROLOL - The cardioselective BB
 Take home message
Introduction
 Raymond P. Alquist discovered the adrenergic
receptors as  and  receptors.
 James Whyte Black, discovered the drug
propanolol (the greatest breakthrough after discovery
of digitalis).
 Since then BB evolved as major group of drugs in
different subsets of cardiovascular disease.
 They have significant mortality benefit in HFrEF
(once contraindicated in HF).
BETA RECEPTORS
Beta Blockers in current cardiovascular practice
Indications for use of BBs
HEART FAILURE
 Describe the magnitude of the problem
 Previous classification of heart failure
 previous theories of heart failure
Beta Blockers in current cardiovascular practice
Neurohormonal model of Heart Failure
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
 BB had a significant effect
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Target Doses of Heart Failure Medical Therapy and Blood Pressure: Insights From the CHAMP-HF Registry---
Eligible patients had a primary diagnosis of HFrEF (LVEF ≤40%) within 12 months of enrollment and were taking at least one oral drug for HF.. 3095 Patients were included
between December 2015 and August 2017. 84% Of patients had NYHA functional class II or III. Median LVEF was 30% . Of 3093 patients, 61% were receiving ACEi/ARB, 12.9%
were receiving ARNI, and 82.7% a BB.
78% had SBP>110mm Hg
Analysis of the contemporary CHAMP-HF cohort of
HFrEF patients revealed that an overwhelming majority
of patients eligible for either BB or ACEi/ARB/ARNI
were not receiving target doses. Most patients were on
less than 50% of guideline-recommended target doses.
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Angina
 Rate pressure product = SBP *HR
 Increases the duration of diastole

Beta Blockers in current cardiovascular practice
arrhythmias
Valvular heart disease
 Mitral stenosis with Atrial fibrillation
 Mitral valve prolapse
Aortic dissection
 IV betablockers to be used
Hypertension
Beta Blockers in current cardiovascular practice
The evidence for a J – curve phenomenon calls for caution especially inpatients with angina
treated with vasoactive drugs leading to low SBP and HR values.
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Myths vs facts
1. Lethargy
2.Diabetes
Beta Blockers in current cardiovascular practice
3.COPD
4.Acute Decompensated Heart Failure
5.Right ventricular dysfunction
6. Peripheral Artery Disease
7.perioperative
contraindications
caution
 1.slow titration – initiation over two weeks, deterioration over one
week.
 2.abrupt stoppage of drug is problematic
 3.
BISOPROLOL
MMP- MEDICINE MANAGEMENT PROGRAM
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
The Cardiac Insufficiency Bisoprolol Study (CIBIS) studied
bisoprolol,a highly selective antagonist of β1 adrenoceptors,
which are found mainly in the heart and especially in
ventricular tissue. That trial showed a non-significant trend
towards 20% lower mortality in the bisoprolol group and 30%
fewer admissions to hospital for worsening heart failure.
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
CIBIS III was the first such trial to compare the
effects of a beta-blocker-first strategy with that
of an ACE-inhibitor first on the ‘hard’ endpoints
of mortality and hospitalization.
It showed that the bisoprolol-first and enalapril-
first groups were comparable with regard to the
primary endpoint, all causemortality or
hospitalization, and all secondary endpoints.
Moreover, bisoprolol-first showed a trend
towards
improved early survival (31% reduction in 1-year
mortality,P =0.065). This suggests that during
early treatment of CHF, before combination
therapy can be initiated, a beta-blocker-first
strategy might be predicted to improve
survival, allowing a greater number of
patients to subsequently
benefit from combined beta-blockade and
ACE-inhibition, as well as other drugs and
interventions.
The Cardiac Insufficiency Bisoprolol (CIBIS) III trial examined the optimum
order of initiating CHF treatment in 1010 patients (65 years), with stable,
mildly, or moderately symptomatic, systolic CHF. Patients were randomized to
initial monotherapy
with bisoprolol for up to 6 months, followed by the addition of enalapril, or the
opposite sequence. Mean follow-up was 1.2 years.
The bisoprolol-first and enalapril-first strategies showed similar efficacy for
the combined primary endpoint of mortality or all-cause hospitalization, and
similar safety. Compared with the enalapril-first strategy, the bisoprolol-first
strategy significantly reduced sudden death during the first year on treatment
by 46% (P , 0.05).
Patients who achieved higher doses of the study drugs (particularly
bisoprolol) had substantially and independently lower mortality and
hospitalization risks. Thus, CIBIS III supports a free choice between
bisoprolol and enalapril as initial therapy for stable, mild-to-moderate,
systolic CHF, and suggests that early beta-blockade reduces the risk of
CIBIS III – SUMMARY
Beta Blockers in current cardiovascular practice
Beta Blockers in current cardiovascular practice
Not proven in
 Pulmonary hypertension
 Endstage live disease
Take home message
 Beat blockers are the keys drugs in heart failure, with significant
mortality benefit.
 Beta blockers are indicated in complicated hypertension not in
uncomplicated hypertension.
 Most of the BB are withdrawn because of lethargy,which lasts for
few weeks only.
 All benefits are not class effects, to be chosen individually.
 Abrupt withdrawal of drug is not to be done.
 Not to be used in patients with cocaine usage.
THANK YOU

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Beta Blockers in current cardiovascular practice

  • 1. BETABLOCKERS IN CURRENT CARDIOVASCULAR PRACTICE Dr. Nagula Praveen, MD, DM Assistant Professor of Cardiology, Osmania General Hospital, Hyderabad Email: drpraveennagula@gmail.com Twitter: @kizashipraveen
  • 2. Case 1  A young male,cocaine addictive to be given BB or not?
  • 3.  A young patient with angina,BP 170/100 mm Hg on NTG persistnet chest pain.what to be given?  BB
  • 4.  A patient with HF came with acute decompesnation ,basal crepts  Bb to be continued?
  • 6. Contents  Introduction  Beta Receptors  Indications for usage of BBs  Myths vs facts  Words of caution  Side effects  BISOPROLOL - The cardioselective BB  Take home message
  • 7. Introduction  Raymond P. Alquist discovered the adrenergic receptors as  and  receptors.  James Whyte Black, discovered the drug propanolol (the greatest breakthrough after discovery of digitalis).  Since then BB evolved as major group of drugs in different subsets of cardiovascular disease.  They have significant mortality benefit in HFrEF (once contraindicated in HF).
  • 11. HEART FAILURE  Describe the magnitude of the problem  Previous classification of heart failure  previous theories of heart failure
  • 13. Neurohormonal model of Heart Failure
  • 19.  BB had a significant effect
  • 33. Target Doses of Heart Failure Medical Therapy and Blood Pressure: Insights From the CHAMP-HF Registry--- Eligible patients had a primary diagnosis of HFrEF (LVEF ≤40%) within 12 months of enrollment and were taking at least one oral drug for HF.. 3095 Patients were included between December 2015 and August 2017. 84% Of patients had NYHA functional class II or III. Median LVEF was 30% . Of 3093 patients, 61% were receiving ACEi/ARB, 12.9% were receiving ARNI, and 82.7% a BB. 78% had SBP>110mm Hg Analysis of the contemporary CHAMP-HF cohort of HFrEF patients revealed that an overwhelming majority of patients eligible for either BB or ACEi/ARB/ARNI were not receiving target doses. Most patients were on less than 50% of guideline-recommended target doses.
  • 39. Angina  Rate pressure product = SBP *HR  Increases the duration of diastole 
  • 42. Valvular heart disease  Mitral stenosis with Atrial fibrillation  Mitral valve prolapse
  • 43. Aortic dissection  IV betablockers to be used
  • 46. The evidence for a J – curve phenomenon calls for caution especially inpatients with angina treated with vasoactive drugs leading to low SBP and HR values.
  • 59. caution  1.slow titration – initiation over two weeks, deterioration over one week.  2.abrupt stoppage of drug is problematic  3.
  • 67. The Cardiac Insufficiency Bisoprolol Study (CIBIS) studied bisoprolol,a highly selective antagonist of β1 adrenoceptors, which are found mainly in the heart and especially in ventricular tissue. That trial showed a non-significant trend towards 20% lower mortality in the bisoprolol group and 30% fewer admissions to hospital for worsening heart failure.
  • 73. CIBIS III was the first such trial to compare the effects of a beta-blocker-first strategy with that of an ACE-inhibitor first on the ‘hard’ endpoints of mortality and hospitalization. It showed that the bisoprolol-first and enalapril- first groups were comparable with regard to the primary endpoint, all causemortality or hospitalization, and all secondary endpoints. Moreover, bisoprolol-first showed a trend towards improved early survival (31% reduction in 1-year mortality,P =0.065). This suggests that during early treatment of CHF, before combination therapy can be initiated, a beta-blocker-first strategy might be predicted to improve survival, allowing a greater number of patients to subsequently benefit from combined beta-blockade and ACE-inhibition, as well as other drugs and interventions.
  • 74. The Cardiac Insufficiency Bisoprolol (CIBIS) III trial examined the optimum order of initiating CHF treatment in 1010 patients (65 years), with stable, mildly, or moderately symptomatic, systolic CHF. Patients were randomized to initial monotherapy with bisoprolol for up to 6 months, followed by the addition of enalapril, or the opposite sequence. Mean follow-up was 1.2 years. The bisoprolol-first and enalapril-first strategies showed similar efficacy for the combined primary endpoint of mortality or all-cause hospitalization, and similar safety. Compared with the enalapril-first strategy, the bisoprolol-first strategy significantly reduced sudden death during the first year on treatment by 46% (P , 0.05). Patients who achieved higher doses of the study drugs (particularly bisoprolol) had substantially and independently lower mortality and hospitalization risks. Thus, CIBIS III supports a free choice between bisoprolol and enalapril as initial therapy for stable, mild-to-moderate, systolic CHF, and suggests that early beta-blockade reduces the risk of CIBIS III – SUMMARY
  • 77. Not proven in  Pulmonary hypertension  Endstage live disease
  • 78. Take home message  Beat blockers are the keys drugs in heart failure, with significant mortality benefit.  Beta blockers are indicated in complicated hypertension not in uncomplicated hypertension.  Most of the BB are withdrawn because of lethargy,which lasts for few weeks only.  All benefits are not class effects, to be chosen individually.  Abrupt withdrawal of drug is not to be done.  Not to be used in patients with cocaine usage.

Editor's Notes

  • #71: In a multicentre double-blind randomised placebo controlled trial in Europe, enrolled 2647 symptomatic patients in NYHA III or IV, with LVEF 35% or less receiving standard therapy with diuretics and inhibitors ofangiotensin-converting enzyme.   Randomly assigned patients bisoprolol 1·25 mg (n=1327) or placebo (n=1320) daily, the drug being progressively increased to a maximum of 10 mg per day. Patients were followed up for a mean of 1·3 years. Analysis was by intention to treat.   Findings CIBIS-II was stopped early, after the second interim analysis, because bisoprolol showed a significant mortality benefit. All-cause mortality was significantly lower with bisoprolol than on placebo (156 [11·8%] vs 228 [17·3%] deaths with a hazard ratio of 0·66 (95% CI 0·54–0·81, p<0·0001). There were significantly fewer sudden deaths among patients on bisoprolol than in those on placebo (48 [3·6%] vs 83 [6·3%] deaths), with a hazard ratio of 0·56 (0·39–0·80, p=0·0011). Treatment effects were independent of the severity or cause of heart failure.