Compared with other beta-blockers, carvedilol may lead to better outcomes in patients with heart failure and acute myocardial infarction, a meta-analysis showed.
In pooled results, including those from the COMET trial, carvedilol significantly reduced all-cause mortality in patients with heart failure compared with several beta 1 selective beta-blockers (24.1% versus 28.6%; RR 0.85, 95% CI 0.78 to 0.93), according to James H. O'Keefe, MD, of MidAmerica Heart Institute at Saint Luke's Hospital in Kansas City, Mo., and colleagues.
A similar reduction was seen among patients with acute MI in a fixed-effects model (RR 0.55, 95% CI 0.32 to 0.94) but not in a random-effects model (RR 0.56, 95% CI 0.26 to 1.12), the researchers reported online in the American Journal of Cardiology.
"Although a large, randomized, multicenter trial is required to confirm the results of this meta-analysis in patients with acute MI, COMET has confirmed carvedilol's efficacy over metoprolol in patients with systolic heart failure," they wrote. "Thus, clearly for patients with systolic heart failure, carvedilol should be considered the beta-blocker of first choice."
Guidelines on acute coronary syndromes, acute MI, and heart failure recommend beta-blockers as first-line therapy, but do not provide any guidance on selecting one drug over another.
Because carvedilol has been shown to have "pleiotropic effects (antioxidant and vasodilating), which are not shared by the commonly prescribed beta 1 selective beta-blockers," the researchers performed a systematic review and meta-analysis to explore whether carvedilol results in superior outcomes compared several of those types of
drugs, including atenolol, bisoprolol, metoprolol, and nebivolol (Bystolic).
They identified 11 randomized trials that directly compared carvedilol with one of the other beta-blockers -- three in acute MI and eight in systolic heart failure populations. The trials included a total of 5,207 patients (median of 150 patients per trial). The largest trial was the 3,029-patient COMET, which compared carvedilol and metoprolol in patients with heart failure.
Through a median follow-up of 12 months, although carvedilol significantly reduced all-cause mortality, it did not reduce heart failure readmissions (RR 0.98, 95% CI 0.93 to 1.03), "suggesting a discordant relative effect of these agents on mortality versus overall cardiac compensation," according to the authors.
In patients with acute MI, carvedilol did not reduce nonfatal MI versus the other agents (RR 0.61, 95% CI 0.31 to 1.22).
There were few differences in outcomes between carvedilol and the other agents in individual trials, but in the four trials pitting metoprolol against carvedilol in patients with heart failure, carvedilol was significantly better at preventing all-cause mortality (RR 0.86, 95% CI 0.78 to 0.94).
O'Keefe and colleagues noted several potential mechanisms to explain the improvement in outcomes observed with carvedilol compared with the beta 1 selective beta-blockers.
Carvedilol has been shown to have antiarrhythmic effects that are not as pronounced with the other agents, which "would potentially lead to better reductions in sudden cardiac death and all-cause mortality in patients with acute MIs and those with heart failure," they wrote.
In addition, they wrote, "improvements in ejection fraction, symptomatic functional class, stroke volume, stroke work, cardiac output, insulin sensitivity, and adrenergic activity with carvedilol, along with a potential increase in the risk for death with beta 1 selective beta-blockers if strict compliance is not followed, all may contribute to the overall morbidity and mortality benefits noted with carvedilol compared with beta 1 selective beta-blockers."
The researchers specifically addressed the extensive use of atenolol.
"Atenolol has not been shown to improve long-term cardiovascular prognosis after acute MI, nor has it been shown to be effective for improving outcomes in patients with heart failure," they wrote. "Additionally, when used for hypertension, atenolol does not protect against heart disease or reduce mortality despite lowering elevated blood pressure."
"The fact that atenolol continues to be one of most widely prescribed beta-blocker(presumably because of habit) is indefensible from a scientific perspective," they wrote.
Some limitations of the analysis noted by the researchers included the fact that not all of the trials were double-blind, the relatively small patient numbers in almost all of the trials, and the variation in dosing across the studies.
Med-P
------------------------- *Leave a comments, questions or even a suggestions below this post. Your expressions are always welcomed.
A similar reduction was seen among patients with acute MI in a fixed-effects model (RR 0.55, 95% CI 0.32 to 0.94) but not in a random-effects model (RR 0.56, 95% CI 0.26 to 1.12), the researchers reported online in the American Journal of Cardiology.
"Although a large, randomized, multicenter trial is required to confirm the results of this meta-analysis in patients with acute MI, COMET has confirmed carvedilol's efficacy over metoprolol in patients with systolic heart failure," they wrote. "Thus, clearly for patients with systolic heart failure, carvedilol should be considered the beta-blocker of first choice."
Guidelines on acute coronary syndromes, acute MI, and heart failure recommend beta-blockers as first-line therapy, but do not provide any guidance on selecting one drug over another.
Because carvedilol has been shown to have "pleiotropic effects (antioxidant and vasodilating), which are not shared by the commonly prescribed beta 1 selective beta-blockers," the researchers performed a systematic review and meta-analysis to explore whether carvedilol results in superior outcomes compared several of those types of
drugs, including atenolol, bisoprolol, metoprolol, and nebivolol (Bystolic).
They identified 11 randomized trials that directly compared carvedilol with one of the other beta-blockers -- three in acute MI and eight in systolic heart failure populations. The trials included a total of 5,207 patients (median of 150 patients per trial). The largest trial was the 3,029-patient COMET, which compared carvedilol and metoprolol in patients with heart failure.
Through a median follow-up of 12 months, although carvedilol significantly reduced all-cause mortality, it did not reduce heart failure readmissions (RR 0.98, 95% CI 0.93 to 1.03), "suggesting a discordant relative effect of these agents on mortality versus overall cardiac compensation," according to the authors.
In patients with acute MI, carvedilol did not reduce nonfatal MI versus the other agents (RR 0.61, 95% CI 0.31 to 1.22).
There were few differences in outcomes between carvedilol and the other agents in individual trials, but in the four trials pitting metoprolol against carvedilol in patients with heart failure, carvedilol was significantly better at preventing all-cause mortality (RR 0.86, 95% CI 0.78 to 0.94).
O'Keefe and colleagues noted several potential mechanisms to explain the improvement in outcomes observed with carvedilol compared with the beta 1 selective beta-blockers.
Carvedilol has been shown to have antiarrhythmic effects that are not as pronounced with the other agents, which "would potentially lead to better reductions in sudden cardiac death and all-cause mortality in patients with acute MIs and those with heart failure," they wrote.
In addition, they wrote, "improvements in ejection fraction, symptomatic functional class, stroke volume, stroke work, cardiac output, insulin sensitivity, and adrenergic activity with carvedilol, along with a potential increase in the risk for death with beta 1 selective beta-blockers if strict compliance is not followed, all may contribute to the overall morbidity and mortality benefits noted with carvedilol compared with beta 1 selective beta-blockers."
The researchers specifically addressed the extensive use of atenolol.
"Atenolol has not been shown to improve long-term cardiovascular prognosis after acute MI, nor has it been shown to be effective for improving outcomes in patients with heart failure," they wrote. "Additionally, when used for hypertension, atenolol does not protect against heart disease or reduce mortality despite lowering elevated blood pressure."
"The fact that atenolol continues to be one of most widely prescribed beta-blocker(presumably because of habit) is indefensible from a scientific perspective," they wrote.
Some limitations of the analysis noted by the researchers included the fact that not all of the trials were double-blind, the relatively small patient numbers in almost all of the trials, and the variation in dosing across the studies.
Med-P
------------------------- *Leave a comments, questions or even a suggestions below this post. Your expressions are always welcomed.
2 comments:
Can science predict violent behavior and help prevent tragedies like Newtown, Connecticut? Science, as it usually does, has some surprising and kind of scary things to tell us. Apparently, no matter what kind of life you lead, scientists can still figure out who you'll be at 30 based on who you were as a toddler.
predict science
water pollution
who is edgar casey
cayce edga
are edgar cayce
what is the environment
environment topics
environment
seminar topics
Scientists look at weather to predict illness outbreaks.
predict science
water pollution
who is edgar casey
cayce edga
are edgar cayce
what is the environment
environment topics
environment
seminar topics
Post a Comment