The effects of metoprolol and captopril on heart rate variability in patients with idiopathic dilated cardiomyopathy

Comparative Efficacy of Different Drugs for the Treatment of Dilated Cardiomyopathy: A Systematic Review and Network Meta-analysis

BACKGROUND AND OBJECTIVE

At present, the therapies of dilated cardiomyopathy concentrated on the symptoms of heart failure and related complications. The study is to evaluate the clinical efficacy of a combination of various conventional and adjuvant drugs in treating dilated cardiomyopathy via network meta-analysis.

METHODS

The study was reported according to the PRISMA 2020 statement. From inception through 27 June 2022, the PubMed, Embase, Cochrane library, and Web of Science databases were searched for randomized controlled trials on medicines for treating dilated cardiomyopathy. The quality of the included studies was evaluated according to the Cochrane risk of bias assessment. R4.1.3 and Revman5.3 software were used for analysis.

RESULTS

There were 52 randomized controlled trials in this study, with a total of 25 medications and a sample size of 3048 cases. The network meta-analysis found that carvedilol, verapamil, and trimetazidine were the top three medicines for improving left ventricular ejection fraction (LVEF). Ivabradine, bucindolol, and verapamil were the top 3 drugs for improving left ventricular end-diastolic dimension (LVEDD). Ivabradine, L-thyroxine, and atorvastatin were the top 3 drugs for improving left ventricular end-systolic dimension (LVESD). Trimetazidine, pentoxifylline, and bucindolol were the top 3 drugs for improving the New York Heart Association classification (NYHA) cardiac function score. Ivabradine, carvedilol, and bucindolol were the top 3 drugs for reducing heart rate (HR).

CONCLUSION

A combination of different medications and conventional therapy may increase the clinical effectiveness of treating dilated cardiomyopathy. Beta-blockers, especially carvedilol, can improve ventricular remodeling, cardiac function, and clinical efficacy in patients with dilated cardiomyopathy (DCM). Hence, they can be used if patients tolerate them. If LVEF and HR do not meet the standard, ivabradine can also be used in combination with other treatments. However, since the quality and number of studies in our research were limited, large sample size, multi-center, and high-quality randomized controlled trials are required to corroborate our findings.

Evaluation of heart rate variability using 24-hour Holter electrocardiography in hypertensive patients

BACKGROUND

Hypertension (HTN) remains a serious risk factor for cardiovascular mortality across the world. Hypertensive state has been shown to be associated with autonomic nervous function. This study aimed to explore the association between autonomic nervous impairment assessed by heart rate variability (HRV) and HTN.

METHODS

A total of 52 hypertensive and 55 non-hypertensive patients were consecutively studied using 24-hour Holter. The hypertensive patients were grouped into controlled blood pressure (BP) and uncontrolled BP. This study compared HRV in non-hypertensive and hypertensive patients; and hypertensive patients with controlled and uncontrolled BP. HRV parameters include time and frequency domain.

RESULTS

Mean age for hypertensive and non-hypertensive patients were 53.58 ± 14.31 and 44.89 ± 16.63 years old, respectively. Median (IQR) SDNN for hypertensive and non-hypertensive group were 109.00 (90.00-145.00) and 129.00 (107.00-169.00), respectively. SDNN, ASDNN, rMSSD, pNN50, BB50, VLF, and HF values were significantly lower in the hypertensive group compared to non-hypertensive group (all P < .05). A multiple regression analysis showed that HRV parameters: SDANN, ASDNN, rMSSD, and LF values were independent risk factors of HTN. SDNN, SDANN, ASDNN, VLF, LF, and HF values were significantly lower in the uncontrolled BP compared to controlled BP group (all P < .05). A multiple regression analysis showed that HRV parameters: SDNN, SDANN, rMSSD, and HF values were independent risk factors of uncontrolled BP in hypertensive patients.

CONCLUSIONS

Our study showed that cardiac autonomic nervous impairment, as demonstrated by reduced HRV, is significantly associated with HTN. Decreased HRV was more evident in uncontrolled BP than in controlled BP group.

Beyond pharmacological treatment: an insight into therapies that target specific aspects of heart failure pathophysiology

Heart failure is a common syndrome associated with substantial morbidity and mortality. The management of symptoms and the strategies for improving prognosis have largely been based on pharmacological treatments. The pathophysiology of heart failure is complex because of the multiple causes responsible for this syndrome. This Series paper presents some examples of advances in heart failure management, in which the treatment specifically targets the underlying pathophysiological mechanisms responsible for the symptoms. These treatments include treatment of electromechanical dyssynchrony and dysrhythmia by cardiac resynchronisation and implantable cardioverter-defibrillators; neurohumoral modification by baroreflex and vagal stimulation; prevention of adverse cardiac remodelling by interatrial shunts; and finally targeting the myocardium directly by cell therapy in an attempt to regenerate new myocardial cells.

Secondary outcomes of a behavioral sleep intervention: A randomized clinical trial

OBJECTIVE

Nearly 80% of cancer patients struggle with insomnia, which is associated with decreased heart rate variability (HRV) and quality of life (QOL). The aim of this secondary analysis was to evaluate the possible effects of Brief Behavioral Therapy for Cancer-Related Insomnia (BBT-CI), delivered during chemotherapy visits, on QOL and HRV in patients with breast cancer (BC).

METHOD

QOL and HRV data were obtained during a pilot clinical trial assessing the feasibility and effects of BBT-CI on insomnia. A total of 71 BC patients (mean age = 52.5 years) were randomly assigned to either BBT-CI or a healthy-eating control intervention (HEAL). BBT-CI and HEAL were delivered over 6 weeks (2 face-to-face sessions plus 4 phone calls) by trained staff at 4 National Cancer Institute-funded Community Oncology Research Program clinics. QOL was measured with the Functional Assessment of Cancer Therapy (FACT-G) and HRV with the Firstbeat device at baseline and after intervention.

RESULTS

There were significant improvements in QOL after intervention for BBT-CI (FACT-G, p = .009; FACT-B, p = .016; ANCOVA) and 5-min supine HRV measures (SDNN, p = .005; rMSSD, p = .004; HF, p = .009; ANCOVA) compared with HEAL.

CONCLUSIONS

Patients randomized to BBT-CI showed improvements in QOL and HRV, providing support for BBT-CI's possible benefit when delivered in the community oncology setting by trained staff. A more definitive efficacy trial of BBT-CI is currently being planned with sufficient statistical power to evaluate the intervention's clinical utility. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cardiovascular function and predictors of exercise capacity in patients with colorectal cancer

BACKGROUND

Patients with colorectal cancer (CRC) often present with dyspnea and fatigue. These are also frequent symptoms in patients with chronic heart failure (CHF).

OBJECTIVES

We hypothesized that similar patterns of cardiovascular perturbations are present in CRC and CHF.

METHODS

We prospectively studied 50 patients with CRC, 51 patients with CHF, and 51 control subjects. The CRC group was divided into 2 subgroups: patients who underwent chemotherapy (n = 26) and chemotherapy-naive patients (n = 24). We assessed exercise capacity (spiroergometry), cardiac function (echocardiography), heart rate variability (Holter electrocardiography), body composition (dual-energy x-ray absorptiometry), and blood parameters.

RESULTS

Compared with the control arm, the left ventricular ejection fraction (CRC group 59.4%; control group 62.5%) and exercise performance as assessed by peak oxygen consumption (peak VO2) (CRC group 21.8 ml/kg/min; control group 28.0 ml/kg/min) were significantly reduced in CRC patients (both p < 0.02). Markers of heart rate variability were markedly impaired in CRC patients compared with control subjects (all p < 0.008). Compared with the control group, the CRC group also showed reduced lean mass in the legs and higher levels of the endothelium-derived C-terminal-pro-endothelin-1 (both p < 0.02). Major determinants of cardiovascular function were impaired in chemotherapy-treated patients and in the chemotherapy-naive patients, particularly with regard to exercise capacity, left ventricular ejection fraction, lean mass, and heart rate variability (all p < 0.05 vs. control subjects).

CONCLUSIONS

Some aspects of cardiovascular function are impaired in patients with CRC. More importantly, our findings were evident independently of whether patients were undergoing chemotherapy.

Ivabradine improves heart rate variability in patients with nonischemic dilated cardiomyopathy

Background

Ivabradine is a novel specific heart rate (HR)-lowering agent that improves event-free survival in patients with heart failure (HF).

Objectives

We aimed to evaluate the effect of ivabradine on time domain indices of heart rate variability (HRV) in patients with HF.

Methods

Forty-eight patients with compensated HF of nonischemic origin were included. Ivabradine treatment was initiated according to the latest HF guidelines. For HRV analysis, 24-h Holter recording was obtained from each patient before and after 8 weeks of treatment with ivabradine.

Results

The mean RR interval, standard deviation of all normal to normal RR intervals (SDNN), the standard deviation of 5-min mean RR intervals (SDANN), the mean of the standard deviation of all normal-to-normal RR intervals for all 5-min segments (SDNN index), the percentage of successive normal RR intervals exceeding 50 ms (pNN50), and the square root of the mean of the squares of the differences between successive normal to normal RR intervals (RMSSD) were low at baseline before treatment with ivabradine. After 8 weeks of treatment with ivabradine, the mean HR (83.6 ± 8.0 and 64.6 ± 5.8, p < 0.0001), mean RR interval (713 ± 74 and 943 ± 101 ms, p < 0.0001), SDNN (56.2 ± 15.7 and 87.9 ± 19.4 ms, p < 0.0001), SDANN (49.5 ± 14.7 and 76.4 ± 19.5 ms, p < 0.0001), SDNN index (24.7 ± 8.8 and 38.3 ± 13.1 ms, p < 0.0001), pNN50 (2.4 ± 1.6 and 3.2 ± 2.2 %, p < 0.0001), and RMSSD (13.5 ± 4.6 and 17.8 ± 5.4 ms, p < 0.0001) substantially improved, which sustained during both when awake and while asleep.

Conclusion

Our findings suggest that treatment with ivabradine improves HRV in nonischemic patients with HF.

Comparative Dose Titration Responses to the Introduction of Bisoprolol or Carvedilol in Stable Chronic Systolic Heart Failure

INTRODUCTION

Several beta blocking drugs (BB) reduce mortality in systolic heart failure (LVSD). We have compared the initial response to introduction of carvedilol and bisoprolol during the standard dose titration protocols for each drug.

METHODS

Approximately 31 unselected patients with stable LVSD were randomised to either carvedilol or bisoprolol measuring blood pressure, heart rate responses and both time and frequency domain heart rate variability (HRV).

RESULTS

One subject died; five withdrew due to intolerable BB related side effects. Carvedilol (n = 13) and bisoprolol (n = 12) attained similar maximal heart rate reduction and induced comparable falls in systolic and diastolic blood pressure. Higher carvedilol doses were associated with lower blood pressure compared to baseline. Individual time domain HRV indices remained unchanged over the initial titration period. Significant increases in triangular Index (TI) were seen with both BB. Carvedilol demonstrated greater (but non-significant) rises in TI compared to Bisoprolol.

CONCLUSIONS

In this study we found similar degrees and rate of onset of HR, HRV and BP response to both carvedilol and bisoprolol in treated LVSD patients. Carvedilol appears to show superior HRV rises compared to bisoprolol during initial titration. Any significant increases in HRV attributable to carvedilol compared to bisoprolol may emerge over a longer treatment interval in LVSD.

Changes in heart rate variability, quality of life, and activity in cardiac resynchronization therapy patients: results of the HF-HRV registry

BACKGROUND

Cardiac resynchronization therapy (CRT) is a viable therapy in the treatment of heart failure (HF). Heart rate variability (HRV) is a prognostic marker of HF and mortality and is a sign of autonomic dysfunction. Acute improvements in measures of HRV have been demonstrated after CRT in small clinical studies. The purpose of the present study was to evaluate changes in HRV and patient outcomes over time and the relationship between these changes in a large generalized sample of patients who received CRT with defibrillator (CRT-D).

METHODS

The Heart Failure-Heart Rate Variability (HF-HRV) registry enrolled 1,421 patients who received a CRT-D device capable of measuring HRV. Patients were followed for a 1-year period. Device diagnostics, including HRV footprint; standard deviation of averaged normal R to R intervals (SDANN); and mean, minimum, and maximum heart rate were measured at each visit, in addition to activity log, New York Heart Association (NYHA) class, and quality of life (QOL) data.

RESULTS

This large sample of HF patients showed an overall improvement in SDANN (69.2 +/- 25.5, 78.5 +/- 27.8, 79.4 +/- 27.2, 80.7 +/- 28.2) and HRV footprint (31.5 +/- 11.8, 33.4 +/- 12.3, 34.2 +/- 12.2, 34.5 +/- 12.3) at the 2 week, 3 month, 6 month, and 12 month visits, respectively (both P < 0.001). There were also significant changes over time in clinical status (improved QOL, increased activity, and improved NYHA, all P < 0.0001), with the greatest changes occurring between the 2 week and 3 month visits.

CONCLUSION

In conclusion, these study results demonstrate that device measured HRV parameters and patient outcomes significantly improve after receipt of CRT.

Changes in Heart Rate Variability Are Correlated to Hemodynamic Improvement With Chronic CARVEDILOL Therapy in Heart Failure

BACKGROUND

Reduced heart rate variability (HRV) has been shown to predict mortality in heart failure (CHF). The relationship between improved cardiac function and improvement in HRV has not been previously studied.

METHODS AND RESULTS

This was substudy of a randomized, placebo-controlled, double-blinded trial of carvedilol of four months duration. Analysis of HRV was performed on 24-hour Holter monitors obtained at baseline and completion of study. All subjects had symptomatic CHF and an left ventricular ejection fraction (LVEF) <0.35. Study medication was titrated over 1 month to 50 mg/day (< or =75 kg) or 100 mg/day (<75 kg). A total of 17 subjects were randomized to carvedilol and 12 to placebo. Treatment with carvedilol was associated with significant increases in total frequency power, very low frequency power, high frequency power, SDNN, the root-mean square of difference of successive RRs, and pNN50. Change in time and frequency domain measures of HRV had a positive correlation with change in LVEF and negative correlation with change in coronary sinus norepinephrine levels.

CONCLUSION

Carvedilol therapy in patients with CHF significantly increased HRV. Change in HRV correlates to improved hemodynamics. This suggests that carvedilol therapy partially normalizes autonomic modulation of heart rate in patients with CHF.

Circadian changes in heart rate turbulence parameters

Heart rate turbulence is a novel method to identify patients at risk of cardiac death, and to date, there are no data concerning its circadian changes. In 46 coronary patients (mean age 63 +/- 8 years) with at least 100 ventricular premature beats in 24-hour Holter monitoring, turbulence onset, turbulence slope, and heart rate variability parameters were calculated in 3 equal 4-hour periods during morning, afternoon, and night. No circadian changes in turbulence onset values were found, while TS displayed significantly lower values during afternoon than during morning or night hours (5.08, vs. 7.08 and 7.99 ms/RR, respectively). Some heart rate variability parameters also showed lower values in the afternoon, not in the morning hours. In conclusion, in hospitalized patients with stable coronary artery disease, turbulence slope shows circadian pattern with lowest values observed in the afternoon when compared to morning and night hours.

Effect of carvedilol on microcirculatory and glucose metabolic regulation in patients with congestive heart failure secondary to ischemic cardiomyopathy

In a randomized (2:1), double-blinded design study, we studied 25 patients with congestive heart failure (66 +/- 9 years, ejection fraction 30 +/- 7%) before and after 23-week treatment with the beta blocker carvedilol 25 mg twice daily (n = 17) or placebo (n = 8) in addition to standard therapy. Using dynamic positron emission tomography, myocardial perfusion at rest and perfusion reserve after dipyridamole (0.56 mg/kg/min) were measured. Myocardial glucose uptake and plasma levels of catecholamines were also estimated. Carvedilol treatment reduced the rate-pressure product (8,781 +/- 2,672 vs 6,342 +/- 1,346, p <0.01) and improved ejection fraction (29 +/- 7% vs 37 +/- 11%, p <0.001), whereas no changes were observed in the control group. Perfusion at rest was unchanged in the placebo group (0.81 +/- 0.17 vs 0.86 +/- 0.23 ml/g/min, p = NS), whereas the carvedilol-treated group showed a significant reduction (0.88 +/- 0.26 vs 0.75 +/- 0.16 ml/g/min, p <0.05). Dipyridamole-induced hyperemia was significantly reduced after carvedilol treatment (1.51 +/- 0.45 vs 1.31 +/- 0.51 ml/g/min, p <0.001), whereas myocardial perfusion reserve was unaltered. Carvedilol did not alter myocardial glucose uptake (0.33 +/- 0.14 vs 0.32 +/- 0.12 micromol/g/min, p = NS) or the plasma catecholamines levels. We therefore conclude that in patients with congestive heart failure, carvedilol reduced resting and hyperemic perfusion. No effect on glucose uptake or catecholamine levels was observed. The reduced perfusion at rest must reflect reduced perfusion demand and thereby a higher threshold for myocardial ischemia and protection against myocardial damage or malignant arrhythmia. These effects may serve as a pathophysiologic explanation for the reduced mortality in patients with congestive heart failure who receive carvedilol.

Heart rate variability and cardiovascular mortality

The autonomic nervous system plays a major role in affecting the cardiac milieu and promoting malignant ventricular activity. The measurement of heart rate variability (HRV) is a noninvasive tool for assessing the status of the autonomic nervous system. A depressed HRV among post-myocardial infarction patients is a well-established risk factor for arrhythmic death. A reduced HRV has also been used to identify diabetic patients with autonomic neuropathy. This paper presents recent developments in the use of HRV, focusing on further refinement and validation of the use of both linear and nonlinear dynamics for sudden death prognostication, evaluation of the effect of specific pharmacologic agents on HRV, and assessment of HRV in health and in specific disease states that have been associated with an increased mortality risk.

CAPRICORN: a story of alpha allocation and beta-blockers in left ventricular dysfunction post-MI

Beta-blocker therapy is beneficial both after myocardial infarction and in mild, moderate and severe chronic heart failure. Recent sub-group analysis of the Goteborg Metoprolol Trial and the AIRE study confirm that patients receiving beta-blockers in the setting of post-MI heart failure fare better than patients not receiving this therapy. For all these reasons the CAPRICORN trial of carvedilol in post-MI LV dysfunction was an important and eagerly awaited trial. The results were presented for the first time at The American College of Cardiology on March 20 2001. CAPRICORN randomised 984 patients to placebo and 975 to carvedilol between 3 and 21 days (mean 10) after a confirmed MI. Patients had to have evidence of a left ventricular ejection fraction 40% or less. All patients had received ACEI therapy for at least 48 hours prior to randomisation. The mean ejection fraction of the patients recruited was 32.7% in the placebo group and 32.9% in the carvedilol group. Follow-up was for a mean of 15 months (maximum 2.7 years). All cause mortality was 15.3% (151 deaths) in the placebo group and 11.9% (116 deaths) in the carvedilol group, giving a hazard ratio of 0.77 (0.60-0.98) and a significance of p = 0.031. And yet this agent will probably not be given a licence for this indication in the European Union and the USA. The reason is one of trial design and statistical declarations. Some way into the trial the Steering Committee decided to change the primary end-point form all-cause mortality to two co-primary end-points and to allocate their alpha power of 0.05 unevenly between the combined end-points of all cause mortality and cardiovascular hospitalisation (alpha 0.045) and all cause mortality (alpha 0.005). In the end neither was achieved, one because of the large number of non-specific hospitalisations for chest pain and the mortality effect because it was allocated a punitive and unachievable target of p < 0.005. The trial is thus officially neutral despite showing convincing clinical benefit. Clearly arcane matters of statistical plans do matter and steering committees should think very carefully before changing the primary end-points of major trials.

Role of beta blockers in congestive heart failure

Prolonged activation of the adrenergic nervous system has adverse consequences on the cardiovascular system in patients with congestive heart failure. Beta adrenergic receptor-blocker therapy modifies these deleterious effects. Beta blockers have been shown to improve myocardial function and survival when used in conjunction with conventional treatment with diuretics, angiotensin-converting enzyme inhibitors, and digoxin. Beta blocker therapy in mild-to-moderate heart failure should not be delayed because it causes some reversal of both neurohormonal compensatory mechanisms and the deleterious myocardial remodeling process. This paper reviews the beneficial effects of beta adrenergic receptor-blocker therapy on the pathophysiology, symptoms, left ventricular function, morbidity, and mortality in patients with congestive heart failure. (c)2000 by CHF, Inc.