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Chu H, Fei F, Su Y, Zhou H. Impact of premorbid use of beta‑blockers on survival outcomes of patients with sepsis: A systematic review and meta‑analysis. Exp Ther Med 2024; 28:300. [PMID: 38868611 PMCID: PMC11168026 DOI: 10.3892/etm.2024.12589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/28/2024] [Indexed: 06/14/2024] Open
Abstract
It is unclear if premorbid use of beta-blockers affects sepsis outcomes. The present systematic review aimed to assess the impact of premorbid beta-blocker use on mortality and the need for mechanical ventilation in patients with sepsis. Embase, Scopus, PubMed and Web of Science were searched for studies comparing outcomes of patients with sepsis based on the premorbid use of beta-blockers. The primary outcome was mortality, and the secondary outcome was the need for mechanical ventilation. The results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). A total of 17 studies including 64,586 patients with sepsis were included. Of them, 8,665 patients received premorbid beta-blockers and 55,921 patients were not treated with premorbid beta-blockers and served as a control group. Pooled analysis of mortality rates revealed that premorbid use of beta-blockers did not affect in-hospital mortality (OR: 0.96; 95% CI: 0.78, 1.18; and I2=63%) but significantly reduced one-month mortality rates (OR: 0.83; 95% CI: 0.72, 0.96; and I2=63%). Combined analysis of adjusted data showed that premorbid beta-blockers were associated with a significant survival advantage in patients with sepsis (OR: 0.81; 95% CI: 0.72, 0.92; and I2=70%). However, there was no effect of premorbid use of beta-blockers on the need for mechanical ventilation (OR: 0.93; 95% CI: 0.66, 1.30); and I2=72%). The results of the present study indicated that premorbid use of beta-blockers is associated with improved survival in patients with sepsis. However, it does not impact the need for mechanical ventilation. The results should be interpreted with caution as the data is observational and unadjusted.
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Affiliation(s)
- Huan Chu
- Department of Critical Care Medicine, Huzhou Third Municipal Hospital, The Affiliated Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Fengmin Fei
- Department of Critical Care Medicine, Huzhou Third Municipal Hospital, The Affiliated Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Yao Su
- Department of Critical Care Medicine, Huzhou Third Municipal Hospital, The Affiliated Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Huifei Zhou
- Department of Critical Care Medicine, Huzhou Third Municipal Hospital, The Affiliated Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
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Hong SY, Lai CC, Teng NC, Chen CH, Hsu CC, Chan NJ, Wang CY, Wang YH, Lin YS, Chen L. Premorbid use of selective beta-blockers improves sepsis incidence and course: Human cohort and animal model studies. Front Med (Lausanne) 2023; 10:1105894. [PMID: 37144032 PMCID: PMC10151496 DOI: 10.3389/fmed.2023.1105894] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/22/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Beta-blockers are widely prescribed to manage hypertension and cardiovascular diseases and have been suggested as an attractive therapy to improve the prognosis of sepsis. Herein, we investigated the potential benefits of premorbid selective beta-blocker use in sepsis with a real-world database and explored the underlying mechanism by in vivo and in vitro experiments. Methods A total of 64,070 sepsis patients and 64,070 matched controls who were prescribed at least one anti-hypertensive drug for more than 300 days within 1 year were selected for the nested case-control study. Female C57BL/6 J mice and THP-1 cells stimulated with lipopolysaccharide (LPS) were used for studying systemic responses during sepsis to validate our clinical findings. Results The risk of sepsis was lower in current selective beta-blocker users than in non-users (adjusted OR (aOR), 0.842; 95% CI, 0.755-0.939), and in recent users than in non-users (aOR, 0.773; 95% CI, 0.737-0.810). A mean daily dose of ≥0.5 DDD was associated with a lower risk of sepsis (aOR, 0.7; 95% CI, 0.676-0.725). Metoprolol, atenolol, and bisoprolol users had lower risk of sepsis than non-users. In a LPS-induced sepsis mouse model, mice pre-fed with atenolol had significantly reduced mortality. While atenolol had some mild effects on LPS-induced release of inflammatory cytokines in septic mice, it significantly reduced serum soluble PD-L1 levels. Notably, atenolol treatment reversed the negative correlation of sPD-L1 with inflammatory cytokines in septic mice. Moreover, atenolol markedly downregulated the PD-L1 expression on LPS-stimulated THP-1 monocytes/macrophages via targeting ROS-induced NF-κB and STAT3 activation. Conclusion Atenolol pretreatment can reduce sepsis mortality in mice, and in vivo and in vitro studies of PD-L1 expression suggest a role for atenolol in the modulation of immune homeostasis. These findings may contribute to the reduced incidence of sepsis in hypertensive patients with premorbid treatment with selective beta-blockers, especially atenolol.
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Affiliation(s)
- Shiao-Ya Hong
- Department of Biotechnology and Laboratory Science in Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
- Medical Research Center, Cardinal Tien Hospital, New Taipei City, Taiwan
| | - Chih-Cheng Lai
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan City, Taiwan
| | - Nai-Chi Teng
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Chao-Hsien Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, MacKay Memorial Hospital, Taipei City, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chun-Chun Hsu
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Nai-Ju Chan
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
- *Correspondence: Cheng-Yi Wang,
| | - Ya-Hui Wang
- Medical Research Center, Cardinal Tien Hospital, New Taipei City, Taiwan
- Ya-Hui Wang,
| | - You Shuei Lin
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei City, Taiwan
- Department of Physiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
- You Shuei Lin,
| | - Likwang Chen
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
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Schneider L, Chalmers D, O’Beirn S, Greenberg M, Cave G. Premorbid beta blockade in sepsis is associated with a lower risk of a lactate concentration above the lactate threshold, a retrospective cohort study. Sci Rep 2022; 12:20843. [PMID: 36460714 PMCID: PMC9718750 DOI: 10.1038/s41598-022-25253-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
Sepsis and septic shock represent a significant worldwide mortality burden. A lactate greater than 4 mmol/L is associated with increased mortality in septic patients. This is the concentration at the "lactate threshold" where serum lactate concentrations rise markedly with increased workload in exercise. Hyperlactatemia in both sepsis and exercise is contributed to by adrenergic agonism which stimulates aerobic glycolysis, increasing lactate production and decreasing lactate clearance. Our hypothesis is that in patients with sepsis, treatment with beta blockers in the community will be associated with a lower probability of initial lactate ≥ 4 mmol/L. This was single centre retrospective cohort study. We used an in-house SQL Database for all admissions to ICU/HDU for the 2017-2020 calendar years. The dataset was filtered for an APACHE III Diagnosis of sepsis. T-tests were used for continuous data, Chi squared and Fisher's exact test were used as appropriate to compare proportions. Logistic regression was used to investigate covariate effects. Of the 160 patient records analysed, 49 were prescribed beta blockers. A greater proportion of patients not prescribed beta blockers in the community had a first lactate ≥ 4 mmol/L (p = 0.049). This was robust to regression analysis. There was no difference in the proportion of patients with lactate ≥ 2 mmol/L (p = 0.52). In our cohort patients previously prescribed beta blockers were less likely to have a lactate of ≥ 4 mmol/mL. This supports the proposed mechanism that treatment with beta blockers increases the lactate threshold in sepsis. Further study is warranted.
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Affiliation(s)
- Liam Schneider
- grid.413843.90000 0000 8957 9370Hawkes Bay Hospital Intensive Care Unit, Hastings, New Zealand
| | - Debra Chalmers
- grid.413843.90000 0000 8957 9370Hawkes Bay Hospital Intensive Care Unit, Hastings, New Zealand
| | - Sean O’Beirn
- grid.413843.90000 0000 8957 9370Hawkes Bay Hospital Intensive Care Unit, Hastings, New Zealand
| | - Miles Greenberg
- grid.266886.40000 0004 0402 6494University of Notre Dame, Freemantle, Australia
| | - Grant Cave
- grid.413843.90000 0000 8957 9370Hawkes Bay Hospital Intensive Care Unit, Hastings, New Zealand
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Heliste M, Pettilä V, Berger D, Jakob SM, Wilkman E. Beta-blocker treatment in the critically ill: a systematic review and meta-analysis. Ann Med 2022; 54:1994-2010. [PMID: 35838226 PMCID: PMC9291706 DOI: 10.1080/07853890.2022.2098376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Critical illness may lead to activation of the sympathetic system. The sympathetic stimulation may be further increased by exogenous catecholamines, such as vasopressors and inotropes. Excessive adrenergic stress has been associated with organ dysfunction and higher mortality. β-Blockers may reduce the adrenergic burden, but they may also compromise perfusion to vital organs thus worsening organ dysfunction. To assess the effect of treatment with β-blockers in critically ill adults, we conducted a systematic review and meta-analysis of randomized controlled trials. MATERIALS AND METHODS We conducted a search from three major databases: Ovid Medline, the Cochrane Central Register for Controlled Trials and Scopus database. Two independent reviewers screened, selected, and assessed the included articles according to prespecified eligibility criteria. We assessed risk of bias of eligible articles according to the Cochrane guidelines. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS Sixteen randomized controlled trials comprising 2410 critically ill patients were included in the final review. A meta-analysis of 11 trials including 2103 patients showed a significant reduction in mortality in patients treated with β-blockers compared to control (risk ratio 0.65, 95%CI 0.53-0.79; p < .0001). There was no significant difference in mean arterial pressure or vasopressor load. Quality of life, biventricular ejection fraction, blood lactate levels, cardiac biomarkers and mitochondrial function could not be included in meta-analysis due to heterogenous reporting of outcomes. CONCLUSIONS In this systematic review we found that β-blocker treatment reduced mortality in critical illness. Use of β-blockers in critical illness thus appears safe after initial hemodynamic stabilization. High-quality RCT's are needed to answer the questions concerning optimal target group of patients, timing of β-blocker treatment, choice of β-blocker, and choice of physiological and hemodynamic parameters to target during β-blocker treatment in critical illness.KEY MESSAGESA potential outcome benefit of β-blocker treatment in critical illness exists according to the current review and meta-analysis. Administration of β-blockers to resuscitated patients in the ICU seems safe in terms of hemodynamic stability and outcome, even during concomitant vasopressor administration. However, further studies, preferably large RCTs on β-blocker treatment in the critically ill are needed to answer the questions concerning timing and choice of β-blocker, patient selection, and optimal hemodynamic targets.
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Affiliation(s)
- Maria Heliste
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Erika Wilkman
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Lin SY, Sung FC, Lin CL, Lin CC, Hsu WH, Liao WC, Ho MW, Lin PC, Hsu CY, Kao CH. Association of antihypertensives during hospitalisation with acute respiratory failure in patients with viral pneumonia: A population-based case-control study. Int J Clin Pract 2021; 75:e14776. [PMID: 34510649 DOI: 10.1111/ijcp.14776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/03/2021] [Accepted: 08/30/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We aimed to identify associations between the risk of acute respiratory failure (ARF) and types of antihypertensive agents in patients with viral pneumonia. METHODS In this case-control study, data extracted from the Taiwan National Health Insurance Research Database were analysed. The base population comprised patients with viral pneumonia treated from 2000 to 2013. The case group comprised patients with ARF and the control group comprised participants without ARF. Adjusted odds ratios (ORs) were calculated using a multivariable logistic regression model. RESULTS In total, 4427 viral pneumonia patients with ARF and 4427 matched control participants without ARF were recruited. Patients with diabetes, alcohol-related disease, asthma, chronic kidney disease or end-stage renal disease, chronic obstructive pulmonary disease, cancer, congestive heart failure, stroke, acute pulmonary oedema and shock had increased odds of developing ARF, especially shock (adjusted OR = 49.3; 95% CI = 27.4, 88.7), cancer (12.6; 8.67, 18.2) and stroke (7.51; 5.32, 10.6). Increasing odds of developing ARF were noted in patients using potassium-sparing diuretics (2.95; 1.54, 5.64), loop diuretics (68.2; 48.1, 96.6), calcium channel blockers (1.64; 1.26, 2.13) and angiotensin-converting enzyme inhibitors (1.70; 1.15, 2.53). Patients with prescriptions of α-blockers (0.44; 0.26, 0.74), β-blockers (0.37; 0.26, 0.52), thiazides (0.38; 0.25, 0.59) and angiotensin receptor blockers (0.65; 0.51, 0.83) had lower odds of having ARF. CONCLUSION Patients with viral pneumonia who received α-blockers, β-blockers, thiazides or angiotensin receptor blockers during hospitalisation had a lower risk of developing ARF.
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Affiliation(s)
- Shih-Yi Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Fung-Chang Sung
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Huei Hsu
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Chest Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wei-Chih Liao
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Chest Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Mao-Wang Ho
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Infection, China Medical University Hospital, Taichung, Taiwan
| | - Po-Chang Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Infection, China Medical University Hospital, Taichung, Taiwan
| | - Chung-Y Hsu
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
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Bruning R, Dykes H, Jones TW, Wayne NB, Sikora Newsome A. Beta-Adrenergic Blockade in Critical Illness. Front Pharmacol 2021; 12:735841. [PMID: 34721025 PMCID: PMC8554196 DOI: 10.3389/fphar.2021.735841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/27/2021] [Indexed: 12/31/2022] Open
Abstract
Catecholamine upregulation is a core pathophysiological feature in critical illness. Sustained catecholamine β-adrenergic induction produces adverse effects relevant to critical illness management. β-blockers (βB) have proposed roles in various critically ill disease states, including sepsis, trauma, burns, and cardiac arrest. Mounting evidence suggests βB improve hemodynamic and metabolic parameters culminating in decreased burn healing time, reduced mortality in traumatic brain injury, and improved neurologic outcomes following cardiac arrest. In sepsis, βB appear hemodynamically benign after acute resuscitation and may augment cardiac function. The emergence of ultra-rapid βB provides new territory for βB, and early data suggest significant improvements in mitigating atrial fibrillation in persistently tachycardic septic patients. This review summarizes the evidence regarding the pharmacotherapeutic role of βB on relevant pathophysiology and clinical outcomes in various types of critical illness.
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Affiliation(s)
- Rebecca Bruning
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Hannah Dykes
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Timothy W Jones
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
| | - Nathaniel B Wayne
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, United States
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, United States
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Petitjeans F, Geloen A, Pichot C, Leroy S, Ghignone M, Quintin L. Is the Sympathetic System Detrimental in the Setting of Septic Shock, with Antihypertensive Agents as a Counterintuitive Approach? A Clinical Proposition. J Clin Med 2021; 10:4569. [PMID: 34640590 PMCID: PMC8509206 DOI: 10.3390/jcm10194569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Mortality in the setting of septic shock varies between 20% and 100%. Refractory septic shock leads to early circulatory failure and carries the worst prognosis. The pathophysiology is poorly understood despite studies of the microcirculatory defects and the immuno-paralysis. The acute circulatory distress is treated with volume expansion, administration of vasopressors (usually noradrenaline: NA), and inotropes. Ventilation and anti-infectious strategy shall not be discussed here. When circulation is considered, the literature is segregated between interventions directed to the systemic circulation vs. interventions directed to the micro-circulation. Our thesis is that, after stabilization of the acute cardioventilatory distress, the prolonged sympathetic hyperactivity is detrimental in the setting of septic shock. Our hypothesis is that the sympathetic hyperactivity observed in septic shock being normalized towards baseline activity will improve the microcirculation by recoupling the capillaries and the systemic circulation. Therefore, counterintuitively, antihypertensive agents such as beta-blockers or alpha-2 adrenergic agonists (clonidine, dexmedetomidine) are useful. They would reduce the noradrenaline requirements. Adjuncts (vitamins, steroids, NO donors/inhibitors, etc.) proposed to normalize the sepsis-evoked vasodilation are not reviewed. This itemized approach (systemic vs. microcirculation) requires physiological and epidemiological studies to look for reduced mortality.
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Affiliation(s)
- Fabrice Petitjeans
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
| | - Alain Geloen
- UMR Ecologie Microbienne Lyon (LEM), University of Lyon, 69100 Villeurbanne, France;
| | - Cyrille Pichot
- Critical Care, Hôpital Louis Pasteur, 39108 Dole, France;
| | | | - Marco Ghignone
- Critical Care, JF Kennedy Hospital North Campus, West Palm Beach, FL 33407, USA;
| | - Luc Quintin
- Critical Care, Hôpital d’Instruction des Armées Desgenettes, 69003 Lyon, France;
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Guz D, Buchritz S, Guz A, Ikan A, Babich T, Daitch V, Gafter-Gvili A, Leibovici L, Avni T. β-Blockers, Tachycardia, and Survival Following Sepsis: An Observational Cohort Study. Clin Infect Dis 2021; 73:e921-e926. [PMID: 33460429 DOI: 10.1093/cid/ciab034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Sepsis is associated with excessive release of catecholamines, which causes tachycardia and is correlated with poor clinical outcome. β-Blockers (BBs) may blunt this effect on heart rate (HR). The objective of this study is to assess whether long-term BB therapy is associated with better clinical outcomes in patients with sepsis admitted to internal medicine wards. METHODS We performed a single-center, observational cohort study. We included adult patients who were hospitalized in medicine departments due to sepsis. A propensity score model for BB therapy was used to match patients. The primary outcome was the 30-day all-cause mortality rate. A multivariate analysis was performed to identify risk factors for an adverse outcome. Patients were stratified according to absolute tachycardia (HR ≥100/min) or relative tachycardia at presentation (tachycardia index above the third quartile, with tachycardia index defined as the ratio of HR to temperature). RESULTS A total of 1186 patients fulfilled the inclusion criteria. In the propensity-matched cohort patients given BB treatment were younger (median age [interquartile range], 74 [62-82] vs 81 [68-87] years; P ≤ .001). BB treatment was associated with reduction in 30-day mortality rates for patients with absolute tachycardia (odds ratio, 0.406; 95% confidence interval, .177-.932). Final model with interaction variable of BB treatment with HR was associated with short-term survival (odds ratio, 0.38; 95% confidence interval, .148-.976). Selective BB therapy had a stronger protective effect than nonselective BB therapy. CONCLUSIONS Long-term BB therapy was associated with decreased mortality rate in patients hospitalized with sepsis in internal medicine wards exhibiting absolute and relative tachycardia.
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Affiliation(s)
- Dmitri Guz
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shira Buchritz
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alina Guz
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alon Ikan
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tania Babich
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Vered Daitch
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Gafter-Gvili
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Medicine E, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
| | - Tomer Avni
- Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Kuo MJ, Chou RH, Lu YW, Guo JY, Tsai YL, Wu CH, Huang PH, Lin SJ. Premorbid β1-selective (but not non-selective) β-blocker exposure reduces intensive care unit mortality among septic patients. J Intensive Care 2021; 9:40. [PMID: 33985572 PMCID: PMC8116825 DOI: 10.1186/s40560-021-00553-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND β-blockers may protect against catecholaminergic myocardial injury in critically ill patients. Long-term β-blocker users are known to have lower lactate concentrations and favorable sepsis outcomes. However, the effects of β1-selective and nonselective β-blockers on sepsis outcomes have not been compared. This study was conducted to investigate the impacts of different β-blocker classes on the mortality rate in septic patients. METHODS We retrospectively screened 2678 patients admitted to the medical or surgical intensive care unit (ICU) between December 2015 and July 2017. Data from patients who met the Sepsis-3 criteria at ICU admission were included in the analysis. Premorbid β-blocker exposure was defined as the prescription of any β-blocker for at least 1 month. Bisoprolol, metoprolol, and atenolol were classified as β1-selective β-blockers, and others were classified as nonselective β-blockers. All patients were followed for 28 days or until death. RESULTS Among 1262 septic patients, 209 (16.6%) patients were long-term β-blocker users. Patients with premorbid β-blocker exposure had lower heart rates, initial lactate concentrations, and ICU mortality. After adjustment for disease severity, comorbidities, blood pressure, heart rate, and laboratory data, reduced ICU mortality was associated with premorbid β1-selective [adjusted hazard ratio, 0.40; 95% confidence interval (CI), 0.18-0.92; P = 0.030], but not non-selective β-blocker use. CONCLUSION Premorbid β1-selective, but not non-selective, β-blocker use was associated with improved mortality in septic patients. This finding supports the protective effect of β1-selective β-blockers in septic patients. Prospective studies are needed to confirm it.
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Affiliation(s)
- Ming-Jen Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ruey-Hsing Chou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Critical Care Medicine, Taipei Veterans General Hospital, 112, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Wen Lu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiun-Yu Guo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Lin Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Hsueh Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. .,Department of Critical Care Medicine, Taipei Veterans General Hospital, 112, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan.
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. .,Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Department of Critical Care Medicine, Taipei Veterans General Hospital, 112, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan. .,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Shing-Jong Lin
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.,Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan.,Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
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Tan K, Harazim M, Simpson A, Tan YC, Gunawan G, Robledo KP, Whitehead C, Tang B, Mclean A, Nalos M. Association Between Premorbid Beta-Blocker Exposure and Sepsis Outcomes-The Beta-Blockers in European and Australian/American Septic Patients (BEAST) Study. Crit Care Med 2021; 49:1493-1503. [PMID: 33938711 DOI: 10.1097/ccm.0000000000005034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine the effect of premorbid β-blocker exposure on mortality and organ dysfunction in sepsis. DESIGN Retrospective observational study. SETTING ICUs in Australia, the Czech Republic, and the United States. PATIENTS Total of 4,086 critical care patients above 18 years old with sepsis between January 2014 and December 2018. INTERVENTION Premorbid beta-blocker exposure. MEASUREMENTS AND MAIN RESULTS One thousand five hundred fifty-six patients (38%) with premorbid β-blocker exposure were identified. Overall ICU mortality rate was 15.1%. In adjusted models, premorbid β-blocker exposure was associated with decreased ICU (adjusted odds ratio, 0.80; 95% CI, 0.66-0.97; p = 0.025) and hospital (adjusted odds ratio, 0.83; 95% CI, 0.71-0.99; p = 0.033) mortality. The risk reduction in ICU mortality of 16% was significant (hazard ratio, 0.84, 95% CI, 0.71-0.99; p = 0.037). In particular, exposure to noncardioselective β-blocker before septic episode was associated with decreased mortality. Sequential Organ Failure Assessment score analysis showed that premorbid β-blocker exposure had potential benefits in reducing respiratory and neurologic dysfunction. CONCLUSIONS This study suggests that β-blocker exposure prior to sepsis, especially to noncardioselective β blockers, may be associated with better outcome. The findings suggest prospective evaluation of β-blocker use in the management of sepsis.
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Affiliation(s)
- Kaiquan Tan
- 1 Nepean Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia. 2 Medical Intensive Care Unit, University Hospital and Biomedicine Centre, Pilsen, Charles University Prague, Czech Republic. 3 Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia. 4 Department of Computer Science, Yale University, New Haven, CT. 5 Medistra Hospital, Jakarta, Indonesia. 6 NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia. 7 Centre for immunology and allergy research, Westmead Millennium Institute, Westmead, NSW, Australia
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11
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Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade. Eur J Trauma Emerg Surg 2021; 48:799-810. [PMID: 33847766 PMCID: PMC9001541 DOI: 10.1007/s00068-021-01647-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/11/2021] [Indexed: 12/14/2022]
Abstract
As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.
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12
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Tan K, Harazim M, Tang B, Mclean A, Nalos M. The association between premorbid beta blocker exposure and mortality in sepsis-a systematic review. Crit Care 2019; 23:298. [PMID: 31484576 PMCID: PMC6727531 DOI: 10.1186/s13054-019-2562-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 08/07/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The effect of premorbid β-blocker exposure on clinical outcomes in patients with sepsis is not well characterized. We aimed to examine the association between premorbid β-blocker exposure and mortality in sepsis. METHODS EMBase, MEDLINE, and Cochrane databases were searched for all studies of premorbid β-blocker and sepsis. The search was last updated on 22 June 2019. Two reviewers independently assessed, selected, and abstracted data from studies reporting chronic β-blocker use prior to sepsis and mortality. Main data extracted were premorbid β-blocker exposure, mortality, study design, and patient data. Two reviewers independently assessed the risk of bias and quality of evidence. RESULTS In total, nine studies comprising 56,414 patients with sepsis including 6576 patients with premorbid exposure to β-blockers were eligible. For the primary outcome of mortality, two retrospective studies reported adjusted odds ratios showing a reduction in mortality with premorbid β-blocker exposure. One study showed that premorbid β-blocker exposure decreases mortality in patients with septic shock. Another study showed that continued β-blockade during sepsis is associated with decreased mortality. CONCLUSION This systematic review suggests that β-blocker exposure prior to sepsis is associated with reduced mortality. There was insufficient data to conduct a bona fide meta-analysis. Whether the apparent reduction in mortality may be attributed to the mitigation of catecholamine excess is unclear. TRIAL REGISTRATION PROSPERO, CRD42019130558 registered June 12, 2019.
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Affiliation(s)
- Kaiquan Tan
- Nepean Clinical School, Sydney Medical School, University of Sydney, Penrith, Australia
| | - Martin Harazim
- Medical Intensive Care Unit, Teaching Hospital and Biomedical Centre, Charles University, Alej Svobody 80, 323 00, Pilsen, Czech Republic
| | - Benjamin Tang
- Nepean Clinical School, Sydney Medical School, University of Sydney, Penrith, Australia
- Centre for Immunology and Allergy Research, Westmead Millennium Institute, Westmead, Australia
| | - Anthony Mclean
- Nepean Clinical School, Sydney Medical School, University of Sydney, Penrith, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, Australia
| | - Marek Nalos
- Nepean Clinical School, Sydney Medical School, University of Sydney, Penrith, Australia.
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, Australia.
- Medical Intensive Care Unit, Teaching Hospital and Biomedical Centre, Charles University, Alej Svobody 80, 323 00, Pilsen, Czech Republic.
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13
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The influence of esmolol on septic shock and sepsis: A meta-analysis of randomized controlled studies. Am J Emerg Med 2018; 36:470-474. [DOI: 10.1016/j.ajem.2017.11.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/26/2017] [Accepted: 11/06/2017] [Indexed: 01/07/2023] Open
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