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Beta Blockade and the Heart

Beta Blocker Heart Attack Trial. Randomized 4000 Patients to Placebo Vs. Propranolol20% Reduction in Mortality in Propranolol groupDespite a 17% rise in Triglycerides and a 6% rise in LDL. Beta Blockers in ACUTE MI. Beta Blockers Reduce pain, and reduce need for analgesics presumably by reducing i

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Beta Blockade and the Heart

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    1. Beta Blockade and the Heart John Hakim, M.D Cardiology Fellow West Virginia University Division of Cardiology

    2. Beta Blocker Heart Attack Trial Randomized 4000 Patients to Placebo Vs. Propranolol 20% Reduction in Mortality in Propranolol group Despite a 17% rise in Triglycerides and a 6% rise in LDL

    3. Beta Blockers in ACUTE MI Beta Blockers Reduce pain, and reduce need for analgesics presumably by reducing ischemia Most useful in patients with sinus tachycardia and HTN post MI

    4. Beta Blockers in ACUTE MI Protocol (Braunwald) Exclude patients with Heart Failure (10 cm rales above diaphragm), hypotension <90mmHG, Bradycardia <60 bpm, and Heart Block. Metoprolol in three 5mg boluses q 5 min* Stop if HR <60 or SBP <100mmHg If stable, give oral metoprolol 50mg q6h x 2 days Then switch to 100mg BID or Toprol XL (*IV esmolol useful in patient with relative contraindication.)

    5. What not to give Post Acute MI Unlike Beta Blockers, calcium antagonists are of little value in AMI and may, in fact, be hazardous.

    6. Effects of Beta Blockers Post MI Immediate: reduces cardiac index, heart rate and blood pressure. Net effect is to reduce myocardial oxygen consumption/minute/beat. (Reduces Chest Pain) Reduces infarct Size in Acute MI Diminishes circulating levels of free fatty acids by antagonizing lipolytic effects of catecholamines. (FFA augment O2 consumption and increases incidence of arryhthmias.

    7. Effects of Beta Blockers Post MI (Pre-Thrombolytic Era) ISIS-1 16,000 patients randomized reduction of mortality among patients randomized to IV atenolol Vs. placebo. Meta analysis of 27 trials (27,000+ patients) IV followed by oral beta blockers 15% relative reduction in mortality, non fatal reinfarction, and nonfatal cardiac arrest

    8. Effects of Beta Blockers Post MI TIMI-II trial (Thrombolytics in MI) Recurrent ischemia and reinfarction were reduced by immediate vs. delayed use of metoprolol. mortality and LV function were not improved by immediate metoprolol. Therefore beta-blockers are beneficial, but may not enhance the salvage of myocardium due to early reperfusion.

    9. Effects of Beta Blockers Post MI Current Recommendations Patients with hyperdynamic state ( sinus tachycardia, HTN, no CHF or bronchospasm, no heart block) Patients seen in the first 4 hours of their MI Regardless of whether thrombolytics are used Beta-Blockers indicated for people with persistent or recurrent ischemic pain

    10. Beta Blockers and Idiopathic Dilated Cardiomyopathy Chronic Beta-Blockers increase the number of Beta adrenergic receptors on the Heart Reduced ischemia and more efficient oxygen utilization (Study done w/ metoprolol) Detectable improvement in Cardiac Output (and EF) after three months. Long term structural changes of decline in LV volume and Mass after 12-18 months.

    11. Other Beta Blocker Indications Arrhythmias associated with thyrotoxicosis, pheochromocytoma excess catecholamine state. Arrhythmias initiated by excercise or emotion often respond to propranolol Metoprolol may be helpful in controlling rate of multifocal atrial tachycardia

    12. Question: Peri-operative myocardial ischemia is the single most important reversible risk factor for mortality and cardiovascular complications annually. Is there any way to prevent perioperative myocardial ischemia during non cardiac therapy?

    13. Perioperative Cardiovascular Morbidity and Mortality In patients who are at risk for coronary artery disease who must undergo non-cardiac surgery, treatment with atenolol during hospitalization can reduce mortality and the incidence of cardiovascular complications for as long as 2 years after surgery. (N Eng J Med 1996;335:1713-20)

    14. Perioperative Cardiovascular Morbidity and Mortality In patients with CAD standard practice is to control heart rate pre-op and intra-op. Post-op tachycardia may precipitate ischemia Beta-blockade can modulate the post-op sympathetic response. Preventing ischemia prevents morbidity and mortality.

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