Reliability and Efficacy of Metoprolol and Diltiazem in Patients Having Mild to Moderate Mitral Stenosis with Sinus Rhythm

Abstract

The authors evaluated the effects of beta blockers (metoprolol) and calcium channel blockers (diltiazem) in patients having mild to moderate mitral stenosis (MS) with sinus rhythm. Eighty patients with a complaint of dyspnea with diagnosed MS were included in this study. Patients were randomized into metoprolol and diltiazem groups. The first group received oral diltiazem treatment for 3 months following an i.v. dose of 25 mg diltiazem. The second group received oral metoprolol for 3 months following an i.v. dose of 5 mg metoprolol. All patients performed a treadmill exercise test at the beginning of and after 3 months of treatment. Transthoracic echocardiographic studies were also performed following the i.v. drug administration and after 3 months of treatment. In addition, oxygen uptakes of patients were measured before and after the stress and after 3 months of treatment. Decreases in peak gradient (PG) and mean transmitral gradient (MG) were observed in the metoprolol group after i.v. and oral metoprolol treatment. A prolongation of exercise time in treadmill exercise test (TET) and a decrease in the maximum heart rate after oral metoprolol treatment were noted. Eighteen patients in the metoprolol group had benefited symptomatically from this treatment and complaints of dyspnea were alleviated, whereas no symptomatic relief was seen in the diltiazem group. No significant prolongation was observed in effort times (p>0.05) of the diltiazem group. Transmitral gradients measured via echocardiographic examination did not change (p>0.05). With respect to oxygen uptake rates, a statistically significant decrease was determined in the metoprolol group, whereas no difference was found in diltiazem group. The authors conclude that metoprolol may be useful in patients with MS and can provide symptomatic relief. They did not observe any beneficial effect of diltiazem in these patients.

2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

“…411,412 The greater efficacy of a beta blocker compared with a heart rate-regulating calcium channel blocker has been reported. 413 Some patients with MS have increased bronchial reactivity that may improve with inhaled corticosteroids. 414 Salt restriction and intermittent administration of a diuretic are useful if there is evidence of pulmonary vascular congestion.…”

Effect of Ivabradine on Heart Rate and Duration of Exercise in Patients With Mild-to-Moderate Mitral Stenosis

“…As metoprolol has already proved its favorable hemodynamic effects in patients with MS in a number of clinical trials, 10 , 11 this study with ivabradine points toward a similar beneficial effect in patients of MS.…”

“…Beta-blockers have been shown to decrease the pulmonary capillary pressure and, thus, the gradient across the mitral valve because of their inherent ability to reduce resting and exercising HR. 10 , 11 However, potential adverse effects of beta-blockers that include cardiac effects (severe bradycardia, sinus arrest, atrio-ventricular block, reduced left ventricle contractility), bronchoconstriction, fatigue, mental depression, nightmares, gastrointestinal upset, sexual dysfunction, intensification of insulin-induced hypoglycemia, and cutaneous reactions limit their use in some patients. Ivabradine, which is a specific and selective inhibitor of the I f ion channel, reduces the spontaneous firing rate of sinoatrial pacemaker cells and thus slows HR through a mechanism that is not associated with negative inotropic effects.…”

Drug Therapy for Heart Valve Diseases

“…Though drugs cannot affect the valve obstruction, lengthening diastole by reducing heart rate can ameliorate hemodynamic abnormalities and symptoms. This can be achieved with beta blockers or, less well, with non-dihydropyridine calcium channel blockers 94 , but not with digoxin 95 . As long as pulmonary hypertension and symptoms are mild, such treatment is reasonable and can be beneficially supplemented with diuretics.…”