Effect of beta-adrenergic blockers on the peripheral circulation in patients with peripheral vascular disease.

Hiatt, William R.; Stoll, Sandra Emily; Nies, Alan S.

doi:10.1161/01.cir.72.6.1226

Cited by 67 publications

(28 citation statements)

References 36 publications

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“…Traditionally, β-blockers were considered to exert general cardioprotection against ischaemia and, therefore, also to be effective in patients with concomitant peripheral artery disease. This assumption has been questioned because of presumed negative peripheral haemodynamic consequences of β-blockers, including a decrease in cardiac output and unopposed α-adrenergic drive leading to vasoconstriction 86,87 . In 2013, the British Medical Association declared that β-blockers were contra indicated in severe peripheral artery disease 88 .…”

Section: Myocardial Ischaemiamentioning

confidence: 99%

A 'diamond' approach to personalized treatment of angina

et al. 2017

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Chronic stable angina pectoris is the most prevalent symptomatic manifestation of ischaemic heart disease, and its management is a priority (BOX 1). Current clinical guidelines recommend antianginal therapy to control symptoms, before considering coronary artery revasculariza tion [1][2][3][4] . However, revascularization by either percutaneous coronary angioplasty or CABG surgery is indicated in patients who have significant artery steno sis (50% left main narrowing or proximal three-vessel disease) to reduce myocardial ischaemia and its adverse clinical manifestation. Antianginal agents are approved by documenting that they improve total exercise duration, together with a reduction in daily frequency of chronic stable angina compared with placebo and/or equivalence to an active comparator. Cardiovascular outcomes, although highly advocated, are not a pre requisite for regulatory approval. None of the antianginal drugs has been proved to reduce cardiovascular mortality or the rate of myocardial infarction. When patients are optimally treated, mortality for chronic stable angina is low, which might explain why all trials designed to improve prognosis have been negative. Guidelines recom mend a first-choice and a second-choice approach, based more on tradition and expert opinion, rather than evidence. This categorical approach has been questioned in the past couple of years 5-8 . Newer antianginal drugs, which are classified as second choice, have more evidence-based clinical data that are more contemporary to support their use than is available for the traditional first-choice drugs. Equally, the often-needed combin ation of double or triple therapy is based on expert opinion and not related to the underlying pathophysio logy. What constitutes optimal antianginal treatment, therefore, varies considerably between countries, and the majority of doctors treat their patients according to their own preconceptions.A group of experts with experience and interest in chronic stable angina met at the University of Ferrara, Italy, to discuss an individualized approach to medical treatment of chronic stable angina, on the basis E X P E RT C O N S E N S U S D O C U M E N TA 'diamond' approach to personalized treatment of angina Abstract | In clinical guidelines, drugs for symptomatic angina are classified as being first choice (β-blockers, calcium-channel blockers, short-acting nitrates) or second choice (ivabradine, nicorandil, ranolazine, trimetazidine), with the recommendation to reserve second-choice medications for patients who have contraindications to first-choice agents, do not tolerate them, or remain symptomatic. No direct comparisons between first-choice and second-choice treatments have demonstrated the superiority of one group of drugs over the other. Meta-analyses show that all antianginal drugs have similar efficacy in reducing symptoms, but provide no evidence for improvement in survival. The newer, second-choice drugs have more evidence-based clinical data that are more contemporary than is available for tr...

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Section: Myocardial Ischaemiamentioning

confidence: 99%

A 'diamond' approach to personalized treatment of angina

et al. 2017

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“…25,26 The ␤-blocker nebivolol possesses unique vasodilating, endothelium-dependent, NO-releasing properties, which might be particularly beneficial in patients with PAD, because an impaired reactivity of the vascular endothelium has been associated with adverse outcome in patients with this condition. 26 -29 The issue of the impact of ␤-blockers in PAD has been addressed by few trials, mostly with a small sample size and often only short treatment periods, [13][14][15][16][17][18][19][20][21] and studies comparing ␤-blockers with and without vasodilating effects using a double-blind randomized design are lacking.…”

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confidence: 99%

β-Blockers in Patients With Intermittent Claudication and Arterial Hypertension

et al. 2011

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Abstract-The use of ␤-receptor blockers in peripheral arterial disease is controversial for their impact on vasomotor tone.The ␤-blocker nebivolol possesses vasodilating, endothelium-dependent, NO-releasing properties that might be beneficial in peripheral arterial disease. The aim of the study was to evaluate the effects and tolerability of nebivolol in comparison with metoprolol in these patients. A total of 128 patients with intermittent claudication and essential hypertension were included and double-blind randomized to receive 5 mg of nebivolol (Nϭ65) or 95 mg of metoprolol (Nϭ63) once daily. End points were changes in ankle-brachial index, initial and absolute claudication distance, endothelial function assessed by flow-mediated dilatation of the brachial artery, blood pressure, and quality of life using the claudication scale questionnaire. End point analysis was possible in 109 patients (85.2%). After the 48-week treatment period, ankle-brachial index and absolute claudication distance improved significantly in both patient groups (PϽ0.05 for both), with no difference across treatments. A significant increase of initial claudication distance was found in the nebivolol group. Adjusted mean change of initial claudication distance was 33.9% after nebivolol (Pϭ0.003) and 16.6% after metoprolol (Pϭ0.12) treatment. Quality of life was not influenced by either treatment, and there was no relevant change in flow-mediated dilatation in patients treated with nebivolol or metoprolol (Pϭ0.16). Both drugs were equally effective in lowering blood pressure. In conclusion, ␤-blocker therapy was well tolerated in patients with intermittent claudication and arterial hypertension during a treatment period of Ϸ1 year. In the direct comparison, there was no significant difference between nebivolol and metoprolol. (Hypertension. 2011;58:148-154.)

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“…Moreover, the studies included in this review were performed in Finland, 12,13) Denmark, 14,15) Belgium, 16,17) Israel, 18) and the USA. 16,19) Investigation of racial diŠerences and a-receptor sensitivity in patients with IC is necessary.…”

Section: Discussionmentioning

confidence: 99%

β-Adrenergic Blocking Agents and Intermittent Claudication: Systematic Review

2004

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To clarify contradictions in past reports and the package inserts for b-adrenergic blocking agents ( b-blockers) for patients with intermittent claudication (IC), we investigated the eŠects of b-blockers in patients with IC using the systematic review technique. Data sources were randomized, controlled trials that investigated the eŠects of b-blockers compared with the placebo or untreated group (controls) in patients with IC. Primary endpoints were walking distance and walking time, and secondary endpoints were ankle-brachial index (ABI) and calf blood ‰ow. Nine trials were included in the analysis. Meta-analysis showed that there was a signiˆcant worsening in maximal walking distance and initial claudication distance in patients receiving b-blockers, with standardized mean diŠerences of -0.31 and -0.39 (95 ％ conˆdence interval -0.58 to -0.04 and -0.73 to -0.06, P＝0.03 and 0.02, respectively) compared with controls. There were no signiˆcant diŠerences in maximal walking time (0.07, -0.24 to 0.37), time to onset of claudication (0.12, -0.23 to 0.47), ABI at rest (0.24, -0.30 to 0.78), calf blood ‰ow at rest (0.00, -0.26 to 0.25), and calf blood ‰ow after exercise (-0.23, -0.69 to 0.22). However, only one trial evaluated ABI, and the number of cases is increasing, suggesting that b-blockers do not worsen ABI. There was no evidence that b-blockers prescribed for patients with IC have unsuitable``precautions'' in the package inserts. However, reluctance to administer b-blockers to patients because they have IC is not appropriate.

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Effect of beta-adrenergic blockers on the peripheral circulation in patients with peripheral vascular disease.

Cited by 67 publications

References 36 publications

A 'diamond' approach to personalized treatment of angina

A 'diamond' approach to personalized treatment of angina

β-Blockers in Patients With Intermittent Claudication and Arterial Hypertension

β-Adrenergic Blocking Agents and Intermittent Claudication: Systematic Review

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