BB ของอ ม หร อจะส BB ของ CRH

Company LOGO A systematic review of selective and non-selective beta blockers for prevention of vascular events in patients with acute coronary syndrome or heart failure Supattra Bangpa ID 48210616 Kulnipa Boosri ID 48230004 Faculty of Pharmacy Naresuan University ambulatory clerkchip : 12 November 2010

Outline 1 2 3 4 5 Introduction Methods Results Conclusions Evaluation

Introduction Beta-adrenergic receptor blocking recommended for the treatment of patients with ACS or HF inhibit sympathetic activity: decrease mortality 1 blocker: higher affinity for 1 2 1+2 blocker: affinity for 1 = 2

Introduction Clinical effects of beta-adrenergic blockade in chronic heart failure: a meta-analysis of double-blind, placebo-controlled, randomized trials. Circulation. 1998;98:1184-91. Comparative effects of carvedilol and metoprolol on left ventricular ejection fraction in heart failure: results of a meta-analysis Am Heart J. 2001;141:899-907. 1+2 blocker have better effect on total mortality and cardiovascular morbidity in patients with ACS and HF

Objective To assess the influence of b2-receptor occurrence of vascular events and on all cause mortality in patients with acute coronary syndrome (ACS) or heart failure (HF ).

Methods literature search of Medline, EMBASE and the Cochrane Central Register RCT published from 1981-june 2009 effects of 1 and 1+2 blockers for secondary prevention in patients with ACS or HF studies had a minimum treatment period of 3 mo. primary outcomes: 1. all-cause mortality 2. vascular events

Methods limited to studies of humans and were not restricted to English language studies assessing b-blockers with intrinsic sympathicomimetic, class-iii antiarrhythmic or partial agonist activity, were excluded articles was reviewed by two independently authors disagreement was resolved by third reviewer

Methods strokes vascular events myocardial infarctions fatal pulmonary embolisms venous thromboembolic events

Statistical analysis Relative risks (RR) and 95% confidence intervals (95% CI) DerSimonian and Laird random-effect model Test for heterogeneity:x 2 and I 2 Sensitivity analyses

Results identified & screened n=4258 retrieved for detailed n=85 excluded by using the predefined n=4173 manual reviewed n=2 excluded after full article screening n=48 included in the review n=33 Duplicates with additional information n=6

Summary of treatment Treatment Target dose percent Metoprolol 25-200 mg 33% Carvidilol 25 mg bid 45% Atenolol 50 mg bid 3% Betaxolol 20 mg bid 3% Propanolol 90-160 mg 9% Timolol 10 mg bid 3% Bisoprolol 5-10 mg 6% Bucindolol 50 mg bid 3% Nebivolol 10 mg 3%

Results 14%

Results Total mortality : β1 blocker in patient ACS

Results Total mortality : β1+2 blocker in patient ACS 27%

Results Vascular events: β1 blocker in patient ACS

Results Vascular events: β1+2 blocker in patient ACS 29% 31%

Results Total mortality: β1 blocker in patient HF 24%

Results Total mortality: β1+2 blocker in patient HF 25% 23%

Results Vascular events: β1 blocker in patient HF

Results Vascular events: β1+2 blocker in patient HF

Conclusion Additional b2-receptor blockade may be more effective than b1-receptor blockade alone in preventing total mortality and vascular events in patients with ACS or, to a lesser extent, HF. However, only a few studies directly compared b blockers, and indirect comparisons were subject to heterogeneity, which weakens firm conclusions.

Evaluation

Title Impact factor: 1.20

Abstract

Method Study selection Randomised controlled trial Keyword; RCT, acute coronary syndrome, congestive heart failure, heart muscle ischemia, etc. Limited to studies of human and not restricted to English language Reviewed by two authors third reviewer Assess the agreement between reviewers: kappa (K)statistic

Method Data extraction and quality assessment Baseline characteristics NYHA Composite endpoint study using adequate treatment allocation sequence, proper concealment, binding patient and investigator, completeness of follow-up JADAD scale

Method Statistical analysis Potential biases of comparison between different studies. Analysed by pooling the result Relative risk (RR) and 95% confidence interval DerSimonian and Laird random-effects model Heterogeneity between studies Sensitivity analyses

การนาไปประย กต ใช การศ กษาน ม ความน าเช อถ อ สามารถนาไปอ างอ งใช ก บผ ป วย ACS และ HF ได เน องจากผลการศ กษา ด งกล าวบ งบอกว าการได ร บ B1+2 ช วยลดความเส ยงต อ การเส ยช ว ตและการเก ด vascular event ได แต อย างไรก ตามการพ จารณาเล อกยาให ผ ป วยต องด ความเหมาะสม และยาท ม อย ในโรงพยาบาลน นๆเป นหล ก

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