Effect of β-blockers on mortality in patients with sepsis: A propensity-score matched analysis

The Effectiveness and Safety of Beta Antagonists in Patients With Burns: An Updated Meta-Analysis

AimsThe purpose of this systematic review was to assess the safety and effectiveness of beta antagonists for improving clinical care in burn patients, compared to placebo.MethodsArticles from randomized-controlled trials were identified by a literature search on PubMed and Cochrane. We included relevant trials involving patients with burn. Trials were eligible if they evaluated propranolol and compared to usual care or placebo. We conducted a meta-analysis using a random-effects model.ResultsA total of 2114 patients were included from 14 RCTs. Beta-blocker-treated patients had decreased heart rates (WMD = -14.73, 95% CIs = [-19.14, -10.32]), mean arterial pressure (WMD = -2.76, 95% CIs = [-3.81, -1.70]), rate pressure product (WMD = -1.13, 95% CIs = [-1.56, -0.71]), reduced time for wound healing (WMD = -5.08, 95% CIs [-8.97, -1.18]), and lower resting energy expenditure (WMD = -168.83, 95% CIs [-232.03, -105.63]). However, use of beta-blockers did not reduce mortality rate (WMD = 0.98, 95% CIs [0.68, 1.41]), incidence of sepsis (RR = 0.82, 95% CIs = [0.50, 1.35]), or length of stay in hospital (WMD = -1.50, 95% CIs [-4.76, 1.77]) compared with placebo.ConclusionOur findings indicate that the administration of propranolol to burned patients does not contribute to increased mortality rates, reduced length of hospital stays, or heightened sepsis occurrence. It demonstrates a protective effect on heart function by reducing heart rate, resting energy expenditure, rate pressure product, and wound healing. More randomized-controlled and multi-center studies are needed to effectively establish the use of beta antagonists in burn patients.

Targeting sepsis through inflammation and oxidative metabolism

Infection is a public health problem and represents a spectrum of disease that can result in sepsis and septic shock. Sepsis is characterized by a dysregulated immune response to infection. Septic shock is the most severe form of sepsis which leads to distributive shock and high mortality rates. There have been significant advances in sepsis management mainly focusing on early identification and therapy. However, complicating matters is the lack of reliable diagnostic tools and the poor specificity and sensitivity of existing scoring tools i.e., systemic inflammatory response syndrome criteria, sequential organ failure assessment (SOFA), or quick SOFA. These limitations have underscored the modest progress in reducing sepsis-related mortality. This review will focus on novel therapeutics such as oxidative stress targets, cytokine modulation, endothelial cell modulation, etc., that are being conceptualized for the management of sepsis and septic shock.

Early β-Blocker Use and Clinical Outcomes in Acute Myocardial Injury: A Retrospective Cohort Study

BACKGROUND

Acute myocardial injury is defined by elevated cardiac troponin levels with a rising and/or falling pattern, and is associated with increased mortality risk compared to patients without myocardial injury. The role of β-blockers in patients with acute myocardial injury remains unclear.

METHODS

This multicenter, retrospective cohort study used data from the Tianjin Health and Medical Data Platform to assess the impact of early β-blocker use on 1-year all-cause mortality and major adverse cardiovascular events (MACE) in acute myocardial injury patients, employing a new user and target trial emulation design. Propensity score matching was applied, and Cox regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

After propensity score matching, a total of 25,966 participants were included: 8667 to the β-blocker group and 17,299 to the non-β-blocker group. A total of 4113 deaths (15.8%) and 5795 MACE (22.3%) occurred. Compared with nonusers, β-blocker was associated with the reduced risk of all-cause mortality (HR: 0.89, 95% CI: 0.83-0.95) and MACE (HR: 0.90, 95% CI: 0.85-0.95). In the subgroup analysis, β-blockers were associated with a significantly reduced risk of mortality in patients without stroke (HR 0.85, 95% CI: 0.78-0.93), while no significant association was observed in patients with stroke (HR 1.04, 95% CI: 0.93-1.16).

CONCLUSIONS

Early use of β-blockers is associated with the reduced risk of 1-year mortality in patients with acute myocardial injury. To more accurately assess the therapeutic effects, prospective trials are necessary, and these data provide key research directions for future trials.

Metoprolol use is associated with improved outcomes in patients with sepsis-induced cardiomyopathy: an analysis of the MIMIC-IV database

BACKGROUND

Metoprolol is commonly administered to critically ill patients; however, its effect on mortality in patients with sepsis-induced cardiomyopathy (SICM) remains uncertain. This study aimed to investigate the relationship between metoprolol use and mortality in patients with SICM.

METHODS

Adults with SICM were identified from the MIMIC-IV database. The exposure of interest was metoprolol treatment. The outcomes assessed were 30-day mortality, 1-year mortality, and in-hospital mortality. Kaplan-Meier survival analysis evaluated the effect of metoprolol on these outcomes. Multivariable Cox proportional hazards and logistic regression analyses were performed to determine the correlation between metoprolol treatment and mortality in patients with SICM.

RESULTS

1163 patients with SICM were identified, with 882 receiving metoprolol treatment (MET group) and 281 not receiving metoprolol treatment (NOMET group). Overall, the 30-day, 1-year, and in-hospital mortality rates were 10.2%, 18.2%, and 8.9%, respectively. Significant differences in mortality existed between the groups. Multivariable Cox analysis revealed that patients in the NOMET group had a higher risk of 1-year mortality (adjusted hazard ratio [HR] 2.493; 95% confidence interval [CI] 1.800-3.451; P < 0.001) and 30-day mortality (adjusted HR 4.280; 95%CI 2.760-6.637; P < 0.001). Metoprolol treatment was associated with lower in-hospital mortality (odds ratio [OR] 5.076; 95% CI 2.848-9.047; P < 0.001). Subgroup analysis supported these findings.

CONCLUSION

Metoprolol treatment is associated with reduced all-cause mortality in patients with SICM. Prospective studies are required to validate these findings.

Effectiveness of β-blockers in improving 28-day mortality in septic shock: insights from subgroup analysis and retrospective observational study

Background

In recent years, septic shock remains a common fatal disease in the intensive care unit (ICU). After sufficient fluid resuscitation, some patients still experience tachycardia, which may lead to adverse effects on cardiac function. However, the use of β-blockers in the treatment of septic shock remains controversial. Thus, the purpose of this study is to evaluate the efficacy of β-blockers in the treatment of patients with septic shock and explore the most appropriate patient subgroups for this treatment.

Methods

This retrospective observational study enrolled septic shock patients from the Medical Information Mart for Intensive Care (MIMIC)-IV and used propensity score matching (PSM) to balance some baseline differences between patients with and without β-blockers treatment. The primary outcome was the 28-day mortality. Length of stay (LOS) in the ICU and hospital, and the degree of support for organs such as circulatory, respiratory and renal systems were also assessed. Subgroup analysis and multivariate logistic regression were performed to determine the relationship between β-blockers therapy and 28-day mortality in different patient groups.

Results

A total of 4,860 septic shock patients were enrolled in this study and 619 pairs were finally matched after PSM. Our analysis revealed that β-blocker therapy was associated with a significant improvement in 28-day mortality (21.5% vs. 27.1%; P = 0.020) and led to a prolonged LOS in both the ICU and hospital. Subgroup analysis indicated that there was an interaction between cardiovascular diseases and β-blocker therapy in patients with septic shock. Patients with pre-existing heart disease or atrial arrhythmias were more likely to derive benefits from β-blocker treatment.

Conclusion

We found β-blockers therapy was effective to improve 28-day mortality in patients with septic shock. Patients in the subgroup with cardiovascular diseases were more likely to benefit from β-blockers in mortality.

Impact of β-blockers on in-hospital mortality in patients with heart failure: a retrospective propensity-score matched analysis based on MIMIC-IV database

Introduction

This study assessed the relationship between β-blockers treatment and in-hospital mortality among individuals diagnosed with heart failure (HF).

Methods

A retrospective cohort study was carried out on 9,968 HF patients sourced from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Propensity score matching (PSM) was employed to balance the baseline differences. A multivariate regression analysis was utilized to evaluate the impact of β-blockers therapy on in-hospital mortality.

Results

Among the 9,968 patients, 6,439 (64.6%) were β-blockers users. Before matching, the overall in-hospital mortality rate was 12.2% (1,217/9,968). Following PSM, a total of 3,212 patient pairs were successfully matched. The analysis revealed a correlation between β-blockers therapy and decreased in-hospital mortality (odds ratio 0.51 [0.43-0.60], P < 0.001), as well as shorter Los (length of stay) hospital (β -1.43 [-1.96∼-0.09], P < 0.001). Notably, long-acting β-blockers treatment was linked to a decreased risk of in-hospital mortality (odds ratio 0.55 [0.46-0.65], P < 0.001) and a shorter Los hospital (β -1.21 [-1.80∼-0.63], P < 0.001). Conversely, the research results did not show a notable decrease in-hospital mortality (odds ratio 0.66 [0.44-1.01], P = 0.051) or Los hospital (β -1.01 [-2.2∼-0.25], P = 0.117) associated with short-acting β-blocker therapy.

Discussion

β-blockers therapy in the intensive care unit demonstrates potential benefits in lowering the risk of in-hospital mortality and reducing the duration of hospitalization among patients with HF. Specifically, long-acting β-blockers exhibit a protective effect by significantly decreasing both in-hospital mortality and Los hospital. Conversely, the study did not observe a substantial impact on in-hospital mortality or Los hospital duration in this cohort of patients following the administration of short-acting β-blockers.

Efficacy of β-Blockers in Decreasing Mortality in Sepsis and Septic Shock Patients: A Systematic Review

Sepsis is a life-threatening condition leading to various organ dysfunction due to an underlying infection. Despite providing appropriate treatment, it is still one of the most common causes of death among patients who are admitted to the intensive care unit (ICU). So, multiple studies have been conducted to identify the potential benefits of various drugs in decreasing mortality in sepsis apart from its traditional treatment options. This study aims to identify whether β-blockers play a role in decreasing mortality in sepsis and septic shock patients because of their potential benefits on several organ systems. Medical databases such as Google Scholar, Summon, PubMed Medical Subject Headings (MeSH), PubMed, Science Direct, Cochrane Library, and Multidisciplinary Digital Publishing Institute (MDPI) were systematically searched for relevant publications. The identified articles were assessed based on the inclusion and exclusion criteria, and 11 research articles were finalized, for which quality appraisal was done using appropriate appraisal tools. β-blockers significantly lowered the in-hospital mortality in sepsis and septic shock patients, and they were also associated with better patient outcomes. As there are limited studies, further research needs to be done to explore the role of β-blockers in decreasing mortality in critically ill populations such as sepsis and septic shock patients.

Beta-Blockers as an Immunologic and Autonomic Manipulator in Critically Ill Patients: A Review of the Recent Literature

The autonomic nervous system plays a key role in maintaining body hemostasis through both the sympathetic and parasympathetic nervous systems. Sympathetic overstimulation as a reflex to multiple pathologies, such as septic shock, brain injury, cardiogenic shock, and cardiac arrest, could be harmful and lead to autonomic and immunologic dysfunction. The continuous stimulation of the beta receptors on immune cells has an inhibitory effect on these cells and may lead to immunologic dysfunction through enhancing the production of anti-inflammatory cytokines, such as interleukin-10 (IL-10), and inhibiting the production of pro-inflammatory factors, such as interleukin-1B IL-1B and tissue necrotizing factor-alpha (TNF-alpha). Sympathetic overstimulation-induced autonomic dysfunction may also happen due to adrenergic receptor insensitivity or downregulation. Administering anti-adrenergic medication, such as beta-blockers, is a promising treatment to compensate against the undesired effects of adrenergic surge. Despite many misconceptions about beta-blockers, beta-blockers have shown a promising effect in decreasing mortality in patients with critical illness. In this review, we summarize the recently published articles that have discussed using beta-blockers as a promising treatment to decrease mortality in critically ill patients, such as patients with septic shock, traumatic brain injury, cardiogenic shock, acute decompensated heart failure, and electrical storm. We also discuss the potential pathophysiology of beta-blockers in various types of critical illness. More clinical trials are encouraged to evaluate the safety and effectiveness of beta-blockers in improving mortality among critically ill patients.

The concomitant use of ultra short beta-blockers with vasopressors and inotropes in critically ill patients with septic shock: A systematic review and meta-analysis of randomized controlled trials

Background

Septic shock is associated with systemic inflammatory response, hemodynamic instability, impaired sympathetic control, and the development of multiorgan dysfunction that requires vasopressor or inotropic support. The regulation of immune function in sepsis is complex and varies over time. However, activating Beta-2 receptors and blocking Beta-1 receptors reduces the proinflammatory response by influencing cytokine production. Evidence that supports the concomitant use of ultra short beta-blockers with inotropes and vasopressors in patients with septic shock is still limited. This study aimed to evaluate the use of ultra short beta-blockers and its impact on the ICU related outcomes such as mortality, length of stay, heart rate control, shock resolution, and vasopressors/inotropes requirements.

Methods

A systematic review and meta-analysis of randomized controlled trials including critically ill patients with septic shock who received inotropes and vasopressors. Patients who received either epinephrine or norepinephrine without beta-blockers "control group" were compared to patients who received ultra short beta-blockers concomitantly with either epinephrine or norepinephrine "Intervention group". MEDLINE and Embase databases were utilized to systematically search for studies investigating the use of ultra short beta-blockers in critically ill patients on either epinephrine or norepinephrine from inception to October 10, 2023. The primary outcome was the 28-day mortality. While, length of stay, heart rate control, and inotropes/ vasopressors requirements were considered secondary outcomes.

Results

Among 47 potentially relevant studies, nine were included in the analysis. The 28-day mortality risk was lower in patients with septic shock who used ultra short beta-blockers concomitantly with either epinephrine or norepinephrine compared with the control group (RR (95%CI): 0.69 (0.53, 0.89), I2=26%; P=0.24). In addition, heart rate was statistically significantly lower with a standardized mean difference (SMD) of -22.39 (95% CI: -24.71, -20.06) among the beta-blockers group than the control group. The SMD for hospital length of stay and the inotropes requirement were not statistically different between the two groups (SMD (95%CI): -0.57 (-2.77, 1.64), and SMD (95%CI): 0.08 (-0.02, 0.19), respectively).

Conclusion

The use of ultra short beta-blockers concomitantly with either epinephrine or norepinephrine in critically ill patients with septic shock was associated with better heart rate control and survival benefits without increment in the inotropes and vasopressors requirement.

Prolonged elevated heart rate and 90-Day mortality in acute pancreatitis

Prolonged elevated heart rate (peHR) is recognized as a risk factor for poor prognosis among critically ill patients. However, there is currently a lack of studies investigating the association between peHR and patients with acute pancreatitis. Multiparameter Intelligent Monitoring in Intensive Care IV (MIMIC-IV) database was used to identify patients with acute pancreatitis. PeHR was defined as a heart rate exceeding 100 beats per minute for at least 11 out of 12 consecutive hours. Cox regression analysis was used to assess the association between peHR and the 90-Day mortality. A total of 364 patients (48.9%) experienced a peHR episode. The 90-day mortality was 25%. PeHR is an independent risk factor for 90-day mortality (HR, 1.98; 95% CI 1.53-2.56; P < 0.001). KM survival curves exhibited a significant decrease in the survival rate at 90 days among patients who experienced a peHR episode (P < 0.001, 84.5% vs. 65.1%). We revealed a significant association of peHR with decreased survival in a large cohort of ICU patients with acute pancreatitis.

Heart rate/temperature ratio: A practical prognostic indicator for critically ill patients with sepsis

BACKGROUND

We hypothesize that the heart rate/temperature ratio can predict intensive care unit (ICU) mortality in critical ill patients with sepsis. We aimed to explore the association between the heart rate/temperature ratio and ICU mortality in patients with sepsis.

METHODS

We conducted this study utilizing a comprehensive critical care medicine database. The primary endpoint assessed was ICU mortality. A multivariable logistic regression model was employed to determine the independent impact of the heart rate to temperature ratio on ICU mortality.

RESULTS

The study included 12,321 patients. A nonlinear relationship was observed between the heart rate/temperature ratio and ICU mortality, with an inflection point identified at 2.22. The results from the Multivariable logistic regression analysis revealed that the heart rate/temperature ratio independently contributed to the risk of ICU mortality. In model II, there was a 55 % higher ICU mortality rate with a heart rate/temperature ratio greater than 2.22 than with that less than 2.22 (odds ratio [OR] = 1.55, 95 % confidence interval [CI] 1.35-1.77). Moreover, an elevated heart rate/temperature ratio as a continuous variable showed a positive association with ICU mortality (OR = 2.14; 95 % CI: 1.87-2.45). The impact of the heart rate/temperature ratio on ICU mortality remained consistent across all subgroup variables. The sensitivity analysis results consistently supported the primary outcome, with an E value of 2.47. This suggests that the influence of unmeasured confounders on the observed outcomes was minimal, thereby confirming the robustness of the findings.

CONCLUSIONS

The heart rate/temperature ratio is a readily available and convenient indicator in a clinical setting. Elevated heart rate/temperature ratios, particularly those exceeding 2.22, are strongly linked to a high ICU mortality rate among critically ill sepsis patients.

Effects of beta-blockers use on mortality of patients with acute respiratory distress syndrome: a retrospective cohort study

Introduction: Acute respiratory distress syndrome (ARDS) remains a challenging disease with limited prevention and treatment options. The usage of beta-blockers may have potential benefits in different critical illnesses. This study aimed to investigate the correlation between beta-blocker therapy and mortality in patients with ARDS. Materials and methods: This retrospective cohort study utilized data from the Medical Information Mart for Intensive Care (MIMIC) IV database and focused on patients diagnosed with ARDS. The primary outcome of the study was 30-day mortality. To account for confounding factors, a multivariable analysis was performed. Propensity score matching (PSM) was carried out on a 1:1 ratio. Robust assessments were conducted using inverse probability weighting (IPTW), standardized mortality ratio weighting (SMRW), pairwise algorithms (PA), and overlap weights (OW). Results: A total of 1,104 patients with ARDS were included in the study. Univariate and multivariate Cox regression analyses found that the 30-day mortality for 489 patients (23.7%) who received beta-blockers was significantly lower than the mortality rate of 615 patients (35.9%) who did not receive beta-blockers. After adjusting for potential confounders through PSM and propensity score, as well as utilizing IPTW, SMRW, PA, and OW, the results remained robust, with the hazard ratios (HR) ranging from 0.42 to 0.58 and all p-values < 0.001. Evaluation of the E-values indicated the robustness of the results even in the presence of unmeasured confounding. Conclusion: The findings suggest a potential association between beta-blocker usage and reduced mortality in critically ill patients with ARDS. However, further validation of this observation is needed through randomized controlled trials.