Despite overwhelming evidence of efficacy, most patients with heart failure do not receive proper doses of beta-blockers in clinical practice. There is no good reason for the lack of prescribing. There is no dispute about their efficacy. Patients with heart failure typically tolerate them very well. And they are not expensive.
The beta-blockers used for heart failure are all generic. Yet, a large proportion of patients with heart failure are not being treated with beta-blockers, even though they are life-saving. Heart failure specialists prescribe them enthusiastically, but most patients with heart failure are not treated by specialists. In primary care, beta-blockers are not consistently used.
ESC/ESH Arterial Hypertension (Management of) Guidelines
In one survey , only one-third of patients with heart failure received these drugs. To make matters worse, even when patients are treated with beta-blockers, the drugs are often prescribed in low doses -- despite considerable evidence that higher doses produces better results and are strongly preferred.
What proportion of patients with heart failure are receiving beta-blockers at appropriate doses? I do not know. There is one group of patients with heart failure who are being deprived of beta-blockers entirely -- even though they are treated by specialists in cardiology. Sadly, some children develop heart failure. For most, it results from a genetic condition, a viral infection or after the treatment of cancer. Many children with a cardiomyopathy would benefit from treatment with a beta-blocker.
These drugs are considered accepted therapy in children, but typically, pediatric cardiologists do not prescribe beta-blockers to children with cardiomyopathy. Why not?
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In , a small trial reported that beta-blockers did not work in children , but it enrolled only patients and treated them for only 8 months. However, to show dramatic benefits in adults with heart failure, the trials needed to enroll tens of thousands of patients who were treated for many years. Patients were randomised to receive antihypertensive treatment based on chlorthalidone, amlodipine, lisinopril or doxazosin, although the latter group was halted prematurely. Despite this lack of difference in the primary end-point, the ALLHAT investigators argued that chlorthalidone was superior to amlodipine or lisinopril in the treatment of hypertension due to a better outcome in at least one secondary end-point.
However, ALLHAT was not prospectively powered to look for heart failure as an end-point and heart failure was not defined by traditional criteria. Oedema was not well defined, occurred more commonly in the first study year and was probably influenced by shifting patients abruptly from rational drug regimens to the study drugs on the first day.
At two years of follow-up, mean levels of cholesterol The VALUE trial 10 included 15, high-risk hypertensive patients over 50 years of age who were randomised to antihypertensive treatment based on either valsartan or amlodipine, with the addition of hydrochlorothiazide and open antihypertensive therapy when required. The primary outcome was cardiac morbidity and mortality.
The Best Cardiovascular Drug Many Physicians Won’t Prescribe
After a mean follow-up of 4. The VALUE trial showed important differences in the blood-pressure reduction achieved by the two treatment regimens. This was illustrated by both the percentage of patients at each step of treatment and mean blood pressure in each group at every evaluation. The percentage of patients at the first step of treatment 80mg valsartan or 5mg amlodipine was In contrast, the proportion of patients requiring other antihypertensive drugs in addition to the maximum treatment study dosage mg valsartan or 10mg amlodipine plus 25mg hydrochlorothiazide was In order to separate the blood-pressure-dependent and -independent effects of antihypertensive treatment, the VALUE investigators carried out a special case-control analysis, choosing more than 5, pairs of patients matched for age, sex, risk and, especially, systolic blood pressure.
However, the main conclusion of the VALUE trial was that early blood-pressure reduction was clearly the most important issue for the prevention of cardiovascular disease, at least in high-risk hypertensives, and this was achieved earlier and more effectively by amlodipine treatment. Another important aspect of the VALUE results was the effectiveness of the combination of amlodipine and thiazide diuretic. Although it was previously thought that calcium channel blockers—diuretic combinations were not as effective as diuretics combined with beta-blockers or renin-angiotensin inhibitors due to the complementary mechanisms of action, the results of VALUE demonstrated a higher potency of amlodipine—hydrochlorothiazide than valsartan—hydrochlorothiazide.
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Since then, new hypertension guidelines have emphasised the use of such a combination for blood-pressure control in hypertensives. The ASCOT trial was halted prematurely by the data safety monitoring board on the grounds that excess total mortality was observed in one of the treatment groups. Thus, although no significant differences were observed in the primary objective HR of amlodipine compared with atenolol 0.
This wide range of beneficial effects observed in the amlodipine group was accompanied by better and earlier blood-pressure control in patients receiving such treatment. Wider differences between treatment groups were observed at three months 5. Although diltiazem reduced systolic blood pressure by 3mmHg less than conventional therapy, no differences were observed in the primary objective a combination of stroke, myocardial infarction and cardiovascular death.
The total number of strokes was significantly reduced in the diltiazem group RR 0.
This drug belongs to a class of drugs known as statins. Medical progress, to which Menarini has always tried to give its contribution, has made us accustomed to witnessing a reduction of mortality in cardiovascular events during these past few years.
Changes You Can Make to Manage High Blood Pressure | American Heart Association
The reduction of mortality in myocardial infarction and the improved control of heart failure have and continue to lead to an increase in life expectancy and an improvement in the quality of life in these patients. Chronic stable angina is a debilitating disease. This condition is essentially due to the presence of atherosclerosis of the coronary vessels. The typical symptom of stable angina is chest pain that occurs after exercise or in response to emotional stress and subsides with rest or by taking nitroglycerin.
As described in the European Society of Cardiology ESC Guidelines issued in , stable angina creates a permanent disability of patients often elderly , may require hospitalization and leads to a marked worsening of the quality of life. According to the recommendations of the European Society of Cardiology ESC , the treatment of stable angina should have, as a major goal, the improvement of quality of life by controlling the severity and frequency of symptoms.
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