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СообщениеДобавлено: 30 июл 2013, 11:01 
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Мета-анализ, конечно имеет ограниченную доказательсность, но как-то верится

Beta-blockers for the prevention of sudden cardiac death in heart failure patients: a meta-analysis of randomized controlled trials.

Abstract
BACKGROUND:
In many studies, beta-blockers have been shown to decrease sudden cardiac death (SCD) in heart failure patients; other studies reported mixed results. Recently, several large randomized control trials of beta blockers have been carried out. It became necessary to conduct a systematic review to provide an up-to-date synthesis of available data.
METHODS:
We conducted a meta-analysis of all randomized controlled trials examining the use of beta-blockers vs. placebo/control for the prevention of SCD in heart failure patients. We identified 30 trials, which randomized 24,779 patients to beta-blocker or placebo/control. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Eligible studies had to be randomized controlled trials and provide information on the incidence of sudden cardiac death in heart failure patients. Additional inclusion criteria included: treatment for >30 days and follow-up ≥ 3 months. Studies of patients <18 years, randomization to beta-blocker vs. an angiotensin converting enzyme (without placebo) and/or beta-blocker in both arms were excluded from the analysis. Pre-specified outcomes of interest included SCD, cardiovascular death (CVD), and all-cause mortality and were analyzed according to intention-to-treat.
RESULTS:
We found that beta-blockers are effective in the prevention of SCD [OR 0.69; 95% CI, 0.62-0.77, P < 0.00001], cardiovascular death (CVD) [OR 0.71; 95% CI, 0.64-0.79, P < 0.00001], and all-cause mortality [OR 0.67; 95% CI, 0.59-0.76, P < 0.00001]. Based on the study analysis, 43 patients must be treated with a beta-blocker to prevent one SCD, 26 patients to prevent one CVD and 21 patients to prevent all-cause mortality in one year.
CONCLUSION:
Beta-blockers reduce the risk of sudden cardiac death (SCD) by 31%, cardiovascular death (CVD) by 29% and all-cause mortality by 33%. These results confirm the mortality benefits of these drugs and they should be recommended to all patients similar to those included in the trials.

http://www.ncbi.nlm.nih.gov/pubmed/23848972

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Речь идет о " коллективном" эффекте метопролола сукцината, карведилола, небиволола и бисопролола? Какой разброс эффектов?


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Цель анализа доказать полезность бетаблокаторов, без анализа отдельных препаратов.

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Возможно к бетаблокаторам надо подходить в зависимости от проведенного лечения. Кто получил пластику тому бетаблокаторы надолго не нужны - увеличивают развитие ХСН. Это опять мета - анализ. Вещь совершенно не идельная, но вспоминая историю с нитратами, что они только помогают больным без тромболизиса и ЧТКА, может и бета-блокаторы нуждаются в уточнениях по назначению? Ответ может дать только современное проспективное исследование.


Study Questions Post-MI Beta-blocker Use: Increased HF Risk, No Mortality Benefit

NEW YORK, NY ( updated with commentary ) — A new meta-analysis with more than 100 000 study participants suggests that clinical guidelines recommending the use of beta-blockers in post-MI patients need to be "reconsidered"[1].

The conclusions of the researchers, led by Dr Sripal Bangalore (New York University School of Medicine, NY), are based on their findings showing that while beta-blockers reduce reinfarction and angina in the post-MI setting, there is no reduction in the risk of mortality. More important, the meta-analysis showed that the use of beta-blockers increased the risk of heart failure and cardiogenic shock.

"It's actually a quality metric," Bangalore told heartwire . "In other words, if a hospital discharges a patient with an MI without a beta-blocker they get penalized. It's actually a big deal. If you look at the evidence base, there is not much evidence to strongly support their use. There are a lot of patients who can potentially develop adverse events like cardiogenic shock or heart failure. I think the once-size-fits-all approach is definitely not the way to go."

Published online June 10, 2014 in the American Journal of Medicine, the meta-analysis included 60 clinical trials with 102 003 patients. The patients were stratified into two distinct eras: the reperfusion era, which included 12 trials of 48 806 patients treated in the modern era of thrombolysis and interventional procedures, and the prereperfusion era, which included 48 studies with 31 479 patients.

Currently, the American College of Cardiology Foundation/American Heart Association guidelines for treating STEMI state the use of oral beta-blockers within the first 24 hours is a class I indication. Intravenous beta-blockers are recommended (class IIa) for hypertensive patients or those having ischemia. However, as Bangalore and colleagues point out, the majority of data supporting the use of beta-blockers predate modern reperfusion therapy and current medical management strategies with statins and antiplatelet agents.

In their analysis, the researchers observed a significant interaction between clinical outcomes and reperfusion era. For example, in the prereperfusion era, which mainly included trials with intravenous beta-blockers, there was a significant 14% relative reduction in all-cause mortality, as well as a 13% relative reduction in cardiovascular mortality, a 22% reduction in MI, and a 12% reduction in angina. In this era, there was no increased risk of heart failure or cardiogenic shock.

The mortality benefit was not evident in the reperfusion era, although there was a 28% reduction in MI and a 20% reduction in angina. However, these reductions were traded off against a 10% increased risk of heart failure and a 29% increased risk of cardiogenic shock.

Included within their analysis was the METOCARD trial, a study that investigated the early use of intravenous metoprolol prior to primary PCI vs oral post-PCI use recommended by the clinical guidelines. That study showed that patients who received beta-blockers before PCI had significantly improved outcomes, including higher left ventricular ejection fractions and fewer heart-failure hospitalizations. However, as Bangalore pointed out, the METOCARD study compared the timing of beta-blocker use, not a strategy of beta-blockade vs no beta-blockers, which was the comparison in their analysis.

"That trial did not address what we were trying to ask," he told heartwire , "which was whether or not beta-blockers actually prevent deaths following myocardial infarction."

The researchers acknowledge the analysis of the prereperfusion era might have lacked sufficient power to detect a mortality difference, but they suggest that in this era, "lack of reperfusion and contemporary medical therapy likely resulted in extensive myocardial scarring, providing a substrate for reentrant circuits and fatal ventricular arrhythmias." Reperfusion reduces the likelihood of scars forming, they note, and this might be the reason for the differences between the two eras.

In the reperfusion era, with the increased risk of heart failure and cardiogenic shock, the risk/benefit ratio of using beta-blockers "no longer seems to be favorable," write Bangalore et al.

Источник http://www.medscape.com/viewarticle/827 ... c=116880SK

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Не поняла о чем речь. О лечении бетаблокаторами при ОКС и пластике или вообще в целом при ИБС.

Жолтый Ангел писал(а):
Возможно к бетаблокаторам надо подходить в зависимости от проведенного лечения. Кто получил пластику тому бетаблокаторы надолго не нужны - увеличивают развитие ХСН.

К сожаленью ИБС после пластики не пройдет. А потому и бетаблокаторы будут нужны надолго.


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ответ ли это на вопрос о бета- блокерах при стабильной стенокардии: на medscape: Heartwire
Analysis Questions Beta-blockers in Stable CHD Patients Michael O'Riordan
July 14, 2014?


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СообщениеДобавлено: 17 июл 2014, 08:18 
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Нет, не ответ. Это аргумент только для недавне перенесенного инфаркта миокарда. А как долго их давать? всю ли жизнь?

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