Nat Rev Nephrol 10, — Download citation. Published : 09 September Issue Date : November Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Advanced search. Skip to main content Thank you for visiting nature.
Subjects Drug therapy Hypertension Clinical trial design. Access through your institution. Buy or subscribe. Change institution. Rent or Buy article Get time limited or full article access on ReadCube. References 1 Fleet, J. Google Scholar 3 Wikstrand, J. Article Google Scholar 10 Wong, M. Article Google Scholar Download references. Elliott Authors Sukhbir K. Randhawa View author publications.
View author publications. Conclusions: These findings imply an intra-class difference for beta-blockers when used as first-line antihypertensive prescriptions in real-life clinical settings which inform future clinical guidelines. More outcome studies on the effectiveness of different subtypes within other major antihypertensive drug classes are warranted. All rights reserved. Publication types Comparative Study. Beta-blockers that are metabolised by hepatic enzymes may also interact with medicines that are metabolised via the same pathway.
The NZF interactions checker provides details on medicine interactions, including their clinical significance, available from: www. The indications for beta-blockers have shifted over the years. Originally widely prescribed for hypertension and contraindicated for the treatment of heart failure, beta-blockers now have a limited role in the treatment of hypertension and are routinely prescribed to patients with heart failure.
The benefits of beta-blockers post-myocardial infarction are also no longer as clear as they once were. Beta-blockers or calcium channel blockers are recommended as the first-line anti-anginal medicines. A cardioselective beta-blocker such as bisoprolol or metoprolol succinate will provide the maximum effect with the minimum amount of adverse effects.
Beta-blockers that reduce resting heart rate less than others due to ISA tend not to be used for angina, e. Information on the management of stable angina is available from: bpac.
Beta-blockers are the first-line treatment for long-term symptomatic rate control in patients with a range of cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. Bisoprolol is preferred as it is more cardioselective than metoprolol and may cause more bradycardia. Sotalol should not be used for rate control in atrial fibrillation due to its pro-arrhythmic action. Sotalol is used exclusively for rhythm control in patients with supraventricular and ventricular arrhythmias, but use has declined since the SWORD survival with oral d-sotalol study in the s was discontinued when it was found that sotalol was associated with a higher rate of sudden death when administered to patients after myocardial infarction.
Information on the management of atrial fibrillation is available from: bpac. Bisoprolol, carvedilol or metoprolol succinate are generally prescribed for heart failure in New Zealand; there is no strong evidence of effectiveness for one over another.
Any of these three choices are appropriate if heart failure is associated with ischaemic heart disease, but it is important that the beta-blocker is slowly titrated to maximum tolerated dose. Patients with heart failure with preserved ejection fraction HF-PEF may also be prescribed a beta-blocker if they have other cardiovascular co-morbidities, such as atrial fibrillation or hypertension.
Information on the management of heart failure is available from: bpac. For patients with uncomplicated hypertension beta-blockers are generally a fourth-line option as angiotensin converting enzyme ACE inhibitors, angiotensin II receptor blockers ARBs , diuretics or calcium channel blockers are associated with better outcomes. There is no evidence that one beta-blocker is superior to any other for the management of hypertension.
Information on the management of hypertension is available from: bpac. Beta-blockers are given acutely as first-line treatment post-myocardial infarction to decrease infarct size, increase the threshold for ventricular arrhythmias, and in the long-term, to prevent dysfunctional ventricular remodelling and heart failure. At 6—months post-myocardial infarction prescribers are encouraged to consider withdrawing beta-blockers from patients without atrial fibrillation or heart failure, if re-vascularisation occurred while they were being treated for their myocardial infarction.
If re-vascularisation did not occur the beta-blocker is likely to be required long term to prevent angina or if there is poor ventricular function. This is an evolving area of research and increasingly the evidence appears to support the withdrawal of beta-blockers from patients without other indications for treatment, e.
Information on the management of acute coronary syndromes is available from: bpac. There are two reasons why the optimal duration of beta-blocker treatment post-myocardial infarction is uncertain: A systematic review of sixty trials that divided studies into either the reperfusion era or the pre-reperfusion era, found that beta-blockers reduced mortality in patients post-myocardial infarction in the pre-reperfusion era, but not the reperfusion era.
Guidelines support the use of a beta-blocker for one to three years post-myocardial infarction, 18, 19 but in practice they are now being stopped earlier in patients who are otherwise well, with no signs of angina or heart failure. The adverse effect profile varies between beta-blockers according to their properties Table 1. Tolerance to treatment may be improved with a slow upward titration of the beta-blocker until the maintenance dose is established.
Table 2 summarises recommended choices of beta-blocker, depending on the indication, patient co-morbidities and adverse effects. Beta-blockers should be started at a low dose and slowly titrated to maximum tolerated dose when used to treat patients with heart failure. For other conditions, e. Refer to the New Zealand Formulary for individual beta-blocker dosing regimens: www.
Begin treatment with a beta-blocker at a low dose and gradually increase this to the recommended dose or the maximum tolerated dose. If adverse effects do not resolve, drop back to the previous dose and assess symptom control. Beta-blockers should generally be avoided in patients with asthma.
If a beta-blocker must be used in a patient with asthma, cardioselective beta-blockers, e. There is evidence that beta-blockers are under-prescribed to patients with COPD, yet they provide significant benefit to those with co-existing heart failure; 23 cardioselective beta-blockers are preferred. A systematic review which included 15 studies with a follow-up period ranging from one to seven years found that beta-blockers in patients with COPD significantly decreased overall mortality and exacerbation of COPD.
Cardioselective beta-blockers, e. Malaise, vivid dreams, nightmares and in rare cases hallucinations may be caused by lipid-soluble beta-blockers crossing the blood brain barrier.
Table 2: Summary of indications, recommendations and considerations for the use of beta-blockers for cardiovascular conditions in New Zealand. All beta-blockers are considered to be equally effective although bisprolol or metoprolol may be preferred.
Celiprolol and pindolol tend not to be used. Celiprolol and pindolol have ISA which may reduce bradycardia or peripheral vasoconstriction. Water soluble beta-blockers, e. Polypharmacy: bisoprolol is less likely to interact with other medicines. Renal dysfunction: consider dose adjustments for water-soluble beta-blockers, e. Respiratory disease: cardioselective beta-blockers, e. Bisoprolol or metoprolol; consider withdrawal after 6—12 months if re-vascularised and no other indications. Treatment with beta-blockers is generally long-term, but it should not be regarded as indefinite.
Occasionally it may be necessary to temporarily withdraw treatment, e. In the long-term, the emergence of co-morbidities may make management more complex and it is appropriate to periodically review the benefits and risks of treatment with beta-blockers. Beta-blockers should be withdrawn slowly to prevent the onset of a withdrawal syndrome which in serious cases may include ischaemic cardiac symptoms, e.
The risk of myocardial infarction is increased for older patients during the first month of withdrawal from cardioselective beta-blockers and this increased risk continues for six months. There are no specific guidelines for withdrawing beta-blockers. The dose could be halved every week for patients who needed to withdraw from treatment more rapidly.
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