In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.

Old and new drugs in cardiovascular pharmacotherapy

Papers commented by the Working Group on Cardiovascular Pharmacotherapy

Stefan Agewall, Editor in Chief of EHJ - Cardiovascular Pharmacotherapy provides  his Editor's Choice

Cardiovascular Drug Therapy, Other
Cardiovascular Pharmacotherapy


References to the original articles

Heart rate, beta-blocker use, and outcomes of heart failure with reduced ejection fraction. Ibrahim NE et al. DOI 10.1093/ehjcvp/pvy011

A randomized, double-blind, placebo-controlled trial assessing the efficacy of S66913 in patients with paroxysmal atrial fibrillation. Camm aJ et al DOI 10.1093/ehjcvp/pvy022

Differences in the risk of stroke, bleeding events, and mortality between female and male patients with atrial fibrillation during warfarin therapy. Penttila T et al DOI 10.1093/ehjcvp/pvy026

ESC Council on hypertension position document on the management of hypertensive emergencies. Van den Born BJ et al DOI 10.1093/ehjcvp/pvy032

Baseline low-density lipoprotein cholesterol to predict the extent of cardiovascular benefit from lipid-lowering therapies: a review. Navarese EP et al. DOI 10.1093/ehjcvp/pvy038

Comment

In this issue of European Heart Journal – Cardiovascular Phamacotherapy (Vol 5, Issue 1, January 2019), Dr Januzzi and co-workers from the USA report data from electronic health records in 6071 patients with chronic heart failure with reduced ejection fraction (HFrEF; EF ≤35%) in sinus rhythm with at least 1 year of follow-up and available serial heart rate and medication data. At baseline, 27.9% of patients were on ≥50% of the guideline-directed medical therapy target beta-blocker dose. In adjusted analyses, baseline heart rate was associated with all-cause mortality/HF hospitalization. The authors conclude that in this real-world analysis, high resting heart rate was common in HFrEF patients and associated with adverse outcomes. Opportunities exist to improve guideline-directed medical therapy of beta-blockers and achieve heart rate control. Thus, this study also supports the previous message that adherence to guidelines is very important for the outcome of these patients.(1)

In another study, Otterstad and co-workers from Norway aimed to estimate the effect of oral beta-blockers on mortality in contemporary post-acute myocardial infarction (AMI) patients with low prevalence of HF and/or reduced left ventricular ejection fraction (LVEF). The authors used data from 16 observational studies and found that beta-blocker treatment among 164 408 patients, with a median follow-up time of 2.7 years, was associated with a 26% reduction in all-cause mortality [relative risk (RR) = 0.74, 95% confidence interval (CI) 0.64–0.85]. However, when controlling for bias by the trim and fill simulation method, the effect disappeared (adjusted RR = 0.90, 95% CI 0.77–1.04). The authors concluded that evidence from the study suggested no association between beta-blockers and all-cause mortality in this group of patients.

Anti-arrhythmic drugs (AADs) for the treatment of atrial fibrillation (AF) are associated with limited efficacy and adverse effects.(2–4) Inhibition of the atrial current IKur, absent from the ventricle, is expected to be antiarrhythmic, without adverse cardiac effects. In a clinical trial from Australia and the UK in symptomatic paroxysmal AF patients being considered for ablation, the patients were randomly allocated to a 4-week treatment with the selective IKur inhibitor S66913 (5, 25, or 100 mg orally per day) or placebo. The selective IKur inhibitor S66913 was safe but had no clinically meaningful effect at the time of early termination of the study.

The ESC Working group on Cardiovascular Pharmacotherapy has previously published a review paper on gender differences in the effects of cardiovascular drugs.(5) In this issue of the journal, Penttilä and co-workers from Finland compared the residual risk of stroke, bleeding events, and cardiovascular and all-cause mortality among female and male AF patients taking warfarin. The authors used data from several nationwide registries and laboratory databases, which were linked with the civil registration number of the patients. A total of 54 568 patients with data on the quality of warfarin treatment were included. The conclusion of the study was that there were no differences in the risk of stroke between female and male AF patients taking warfarin. Cardiovascular mortality, all-cause mortality, and risk of bleeding events were lower in females. Hence, female gender was not a risk marker for adverse outcomes in AF patients with proper warfarin therapy.

Dr van den Born and the ESC Council on hypertension publish a position document on the management of hypertensive emergencies. The Council states that hypertensive emergencies are those situations where very high blood pressure values are associated with acute organ damage and therefore require immediate, but careful, blood pressure reduction. The type of acute organ damage is the principal determinant of: (i) the drug of choice; (ii) the target BP; and (iii) the time frame in which blood pressure should be lowered. Key target organs are the heart, retina, brain, kidneys, and large arteries. Patients who lack acute hypertension-mediated end-organ damage do not have a hypertensive emergency and can usually be treated with oral blood pressure-lowering agents and discharged after a brief period of observation.

Dr Navarese from Germany presents a review entitled ‘Baseline low-density lipoprotein cholesterol to predict the extent of cardiovascular benefit from lipid-lowering therapies’.

References of the commented articles

  1. Agewall S. Adherence to guidelines and registry data. Eur Heart J Cardiovasc Pharmacother 2017;3:183–184. doi: 10.1093/ehjcvp/pvx027.
  2. Lip GYH, Coca A, Kahan T, Boriani G, Manolis AS, Olsen MH, Oto A, Potpara TS, Steffel J, Marín F, de Oliveira Figueiredo MJ, de Simone G, Tzou WS, En Chiang C, Williams B. Hypertension and cardiac arrhythmias: executive summary of a consensus document from the European Heart Rhythm Association (EHRA) and ESC Council on Hypertension, endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLEACE). Eur Heart J Cardiovasc Pharmacother 2017;3:235–250. doi: 10.1093/ehjcvp/pvx019.
  3. Agewall S, Camm J. New ESC/EACTS Guidelines for the management of atrial fibrillation. Eur Heart J Cardiovasc Pharmacother 2017;3:71–72. doi: 10.1093/ehjcvp/pvw038.
  4. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37:2893–2962. doi: 10.1093/eurheartj/ehw210.
  5. Tamargo J, Rosano G, Walther T, Duarte J, Niessner A, Kaski JC, Ceconi C, Drexel H, Kjeldsen K, Savarese G, Torp-Pedersen C, Atar D, Lewis BS, Agewall S. Gender differences in the effects of cardiovascular drugs. Eur Heart J Cardiovasc Pharmacother 2017;3:163–182. doi: 10.1093/ehjcvp/pvw042.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.