A Professional Networking Site for Doctors & Medical Students Worldwide
A patient with heart faliure was given Carvedilol. Is there a special pharmacological basis on doing so/
The original thinking was that beta blockers were bad for you is you were in heart failure as they reduce heart rate and myocardial contractility. However when ACE inhibitors were introduced we realised that heart failure brings with it major activation of the sympathetic nervous system and this in turn activates the renin-angiotensin system which then activates the sympathetic nervous system and leading to a vicious cycle of salt and water retention and worsening cardiac perfornance - heart failure begetting heart failure if you like. Beta blockers (particularly when used with ace-inhibitors ) block this cycle. They also probably have a rhythm stabilising effect. There are 4 beta blocker drugs used to treat heart failure carvedilol, metoprolol, bisoprolol and nebivolol. Metoprolol has fallen out of favour (you might like to look at the COMET trial). Carvedilol is a nonselective beta blocker that also vasodilates peripherally potentially reducing some beta blocker side effects. To my knowledge there is very little good data telling us which beta blocker to use in heart failure. I'm not sure if anyone esle knows of any?
Mechanism of Action of BBs in heart failure:
Damage to myocardium after immediate (AMI) or slow onset is not limited; rather resulting in functional decompensation which always leads to widening myocardial damage.This ongoing damage is known as cardiac remodelling. Concentric hypertrophy is due to pressure overload while eccentrici hypertrophy is due to volume overload.
Myocyte, fibroblasts, collagen, the interstitium and the coronary vessels to a lesser extent play a role. Oxidative stress starts a chain of reactions.
Production of Oxygen radicals and hydroxy radicals is increased. Ccavenging enzymes and anti-oxidants and catalases try to overcome this onslaught. When this overwhelmed, mitochondral damage produces further oxidative stress. These processes lead to following 3 major pathways to damamge.
1- Myocyte hypertrophy
As Sadian has mentioned BBs act through neurohormonal mediators to influence this process positively and try to reverse this harmful cardiac remodelling.
These effects are at damaged or prone to damage cell levels. These act through specific receptors in the cell walls. These effects are indedpendent of BP lowering properties.
Aldosterone inhibitors (spirinolactone)
are known benefactors.
New inotropic drugs, New receptor or signal blockers, Nitric oxide donars, metalloproteinases ad Apoptotic inhibitors are being developed.
Found the following studies comparing different beta blockers –
Effects of nebivolol versus carvedilol on left ventricular function in patients with chronic heart failure and reduced left ventricular systolic function.
Randomized trial, found no difference between nebivolol and carvedilol. *
Comparison of effectiveness of carvedilol versus bisoprolol for prevention of postdischarge atrial fibrillation after coronary artery bypass grafting in patients with heart failure
Randomized trial, bisoprolol significantly decreased the risk of AF than carvedilol.**
Effect of selective and non-selective beta-blockers on body weight, insulin resistance and leptin concentration in chronic heart failure.
Randomized trial, carvedilol significantly decreased plasma insulin concentration and insulin resistance compared to bisoprolol. But the sample size is very small.
over louis vuitton handbags,louis vuitton bags the whole baseball bats,softball bats man; mac cosmetics,m a c cosmetics I tory burch outlet,tory burch see ugg australia,uggaustralia.com it in burberry outlet,burberry outlet online his rolex watches for sale,rolex watch faded polo ralph,ralph lauren outlet online blue huarache,nike huarache eyes, beats by dr dre,beats by dre on michael kors outlet online,michael kors outlet his juicy couture outlet,juicy couture handbags broad designer handbags,handbags outlet forehead, vans,vans schuhe on his ray ban sunglasses,ray ban sunglasses outlet delicate lips, chanel outlet,chanel sunglasses on his salomon,salomon schuhe pale shriveled barbour jacket outlet,barbour outlet cheeks. My nike huarache,air huarache uneasy sense ralph lauren factory store,ralph lauren polo of committing north face backpacks,the north face outlet an the north face,north face intrusion louis vuitton outlet online,louis vuitton outlet stores on him steadily increases, in spite of his courteous burberry outlet,burberry outlet store welcome. I true religion jeans outlet,cheap true religion explain to michael kors outlet,michael kors outlet online him new balance,new balance canada that abercrombie,hollister I am michael kors,michael kors capable thomas sabo,thomas sabo of coach outlet usa,coach outlet treating my own case, christian louboutin,christian louboutin shoes having prada sunglasses,prada outlet been woolrich clearance,woolrich jackets myself nike,nike schoenen in jordan release dates,jordan release dates 2015 practice as a medical oakley sunglasses outlet,cheap oakley man; and oakley,gafas oakley this said, tory burch,tory burch sale I lululemon,lululemon australia revert to my interrupted vans shoes,vans outlet excuses. cheap ray ban,ray ban outlet I coach outlet store,coach outlet store online assure him pandora jewelry,pandora bracelet that it is only tory burch sandals,tory burch outlet within hermes,hermes belt the adidas,adidas superstar last tory burch sale,tory burch shoes few chanel,coco chanel moments beats headphones,beats by dr dre that my traveling tommy hilfiger,tommy hilfiger outlet companion replica handbags,knockoff handbags and ugg,uggs I have ralph lauren,ralph lauren become true religion outlet,true religion jeans outlet aware kate spade outlet,kate spade outlet online of puma,puma online the uggs,ugg liberty which our guide ray ban,ray ban zonnebril has ray ban,ray ban sonnenbrillen taken hermes birkin,hermes bags in introducing us, michaelkors.com,michael kors outlet on tiffany and co,tiffany jewelry his own cheap nfl jerseys,nfl jerseys sole responsibility, gucci shoes outlet,gucci mens shoes to omega watches,replica watches the jordan shoes,jordans house. Mr. coach black friday,coach outlet online Dunross yoga pants,lululemon looks michael kors,michael kors taschen at michael kors outlet,michaelkors.com me, nike air max,nike air max thea as toms shoes outlet,toms.com if toms.com,toms outlet he, like the oakley vault,oakley sunglasses guide, failed hollister,abercrombie entirely to understand what my jimmy choo,jimmy choo shoes scruples and vans,vans shoes excuses harrods,harrods london mean. After gucci shoes,gucci shoes outlet a bottega,bottega veneta while uhren,fossil uhren the burberry,burberry sale truth dawns on him. A ugg,ugg boots faint nike free,nike free run smile prada,prada flickers over babyliss,babyliss pro his gucci outlet,gucci shoes face; longchamp,longchamp handbags he michael kors,michael kors canada lays thomas sabo,thomas sabo uk his ralph lauren polo,polo ralph lauren outlet hand in converse,converse shoes a gentle, fatherly way on toms outlet,toms shoes my nike store,nike outlet shoulder.
“We are so nike roshe,roshe run used toms shoes,toms shoes outlet here nike,nike.dk to our longchamp outlet,long champ Shetland air max,nike air max hospitality,” he says, “that bcbg max,bcbg max azria we are gucci,gucci uk slow to understand tommy hilfiger outlet,tommy hilfiger outlet stores the lululemon outlet,yoga pants hesitation which christian louboutin shoes,red bottom shoes a stranger oakley outlet,oakley sunglasses outlet feels in taking advantage tommy hilfiger,www.tommyhilfiger.nl of marc jacobs,marc by marc jacobs it. north face,north face outlet Your guide christian louboutin outlet,louboutin shoes is abercrombie kids,abercrombie.com in no respect michael kors australia,michael kors to blame, gentlemen. timberland shoes,timberland outlet Every house in true religion jeans,true religion outlet these islands which is cheap oakley sunglasses,oakley vault large enough tiffany,tiffany und co to contain louboutin,louboutins a spare wedding dresses,prom dresses room chanel handbags,chanel bags has its salvatore ferragamo,ferragamo shoes Guests’ Chamber, always kept ready for oakley,oakley canada occupation. When polo ralph lauren outlet online,ralph lauren factory store you travel tiffany jewelry,tiffany and co my air max 2015,air max way, you michael kors uk,michael kors come here ugg boots,ugg boots outlet as a louis vuitton outlet stores,vuitton handbags matter tory burch outlet,tory burch of course; swarovski canada,swarovski you north face,the north face stay here eyeglasses online,glasses online as hollisterco,hollister clothing long as retro jordans,jordan retro you like; and, michael kors,michael kors v?skor when hollister clothing store,hollister kids you michael kors outlet,michael kors outlet online go away, eyeglass frames,glasses frames I instyler,instyler ionic styler only do michael kors handbags,michael kors purses my burberry outlet,burberry outlet duty as a michael kors,cheap michael kors good michael kors outlet online,michael kors handbags Shetlander in mcm handbags,mcm backpack accompanying you on nfl jerseys,baseball jerseys the cheap michael kors,michael kors first the north face,northface stage converse,converse chucks of your burberry,burberry online shop journey calvin klein,calvin klein underwear to bid nike roshe run,nike roshe you godspeed. ugg,ugg boots The red bottoms,louboutin customs hollister,hollisterco of nike,nike shoes centuries uggs on sale,ugg boots clearance past elsewhere ralph lauren,ralph lauren are modern jordan retro,air jordan retro customs here. I beg ralph lauren,polo ralph lauren of you pandora,pandora schmuck to new balance,new balance give my ray bans,ray-ban sunglasses servant hollister,hollister online all pandora charms,pandora canada the directions tiffany,tiffany and co which are juicy couture,juicy couture outlet necessary to oakley sunglasses,oakley sunglasses cheap your northface,north face backpacks comfort, just nike air max,air max 2015 as p90x workout,p90x freely as abercrombie fitch,abercrombie and fitch kids you could give ugg australia,ugg them cheap jerseys,cheap nfl jerseys in nike canada,nike store your own house.”
He true religion,true religion jeans turns nike mercurial,nike mercurial vapor aside to nike,nike schuhe ring swarovski,swarovski online a pandora uk,pandora charms hand-bell ferragamo shoes,ferragamo on the table as swarovski,swarovski australia he speaks; ray ban outlet,ray bans and notices hermes outlet,hermes in swarovski crystal,swarovski jewelry the ed hardy,ed hardy clothing guide’s face flat iron,chi hair plain signs that adidas,adidas superstar the man has taken nike store,nike shop offense hair straightener,straightener at my m a c cosmetics,mac makeup disparaging allusion to him.
“Strangers ugg boots,ugg boots cannot be expected ralph lauren,ralph lauren outlet online to understand bcbg dresses,bcbg max our ways, prada outlet,prada shoes Andrew,” says The Master supra shoes,supra footwear of hogan,hogan Books. coach factory outlet online,coach factory outlet “But christian louboutin shoes,louboutin shoes you and I understand louis vuitton outlet,louis vuitton outlet online one cheap oakley,cheap oakley sunglasses another — ray ban,rayban and that cheap jordans,air jordan shoes is enough.”
The hilfiger online shop,tommy hilfiger online guide’s rough coach outlet store online,coach outlet store face mizuno running,mizuno wave reddens cheap nike shoes,nike shoes with burberry handbags,burberry pleasure. If a crowned bebe dresses,bebe clothing king north face jackets,north face on a burberry uk,burberry handbags throne hilfiger outlet,tommy hilfiger had louis vuitton,louis vuitton taschen spoken michael kors handbags,michael kors uk condescendingly to him, he could nike,zapatillas nike hardly polo ralph lauren outlet,ralph lauren have adidas,adidas.se looked more nike free,nike free 5.0 proud of adidas schuhe,adidas online the honor louis vuitton,louis vuitton australia conferred ray-ban sunglasses,ray ban sunglasses than uggs outlet,uggs he polo outlet,ralph lauren outlet looks now. He makes a clumsy attempt new balance outlet,new balance to take giuseppe zanotti,giuseppe shoes the Master’s michael kors outlet online,michael kors outlet online sale hand and ralph lauren online shop,ralph lauren kiss ugg boots,ugg australia it. Mr. ugg boots clearance,uggs outlet Dunross chanel bags,chanel handbags gently repels the long champ,longchamp attempt, and gives him a jordan,michael jordan little oakley sunglasses cheap,oakley sunglasses outlet pat on cheap ugg boots,ugg the head. The guide looks lululemon canada,yoga pants at me and my polo ralph lauren,ralph lauren outlet friend as if he swarovski,swarovski jewelry had michael kors outlet,michael kors outlet online been roshe run,nike roshe honored coach outlet,coach outlet online with the oakley,oakley highest coach factory outlet,coach factory distinction celine handbags,celine bags that an earthly being can rolex watches,replica watches receive. The air max 90,nike air max 90 Master’s hand adidas,adidas canada had nike factory,nike shoes touched him kindly!
In nike air max,air max a moment burberry canada,burberry outlet more, the air jordans,air jordan gardener-groom michael kors outlet online sale,michael kors handbags appears at converse shoes,converse sneakers the nike free run,nike free 5.0 door rolex watches,rolex watches for sale to answer the womens clothing,wholesale clothing bell.
“You katespade,kate spade handbags will burberry outlet online,burberry sale move new balance,new balance the medicine-chest louis vuitton canada,louis vuitton into this kate spade,katespade room, Peter,” says levi's jeans,levis jeans Mr. roshe run,nike roshe Dunross. “And barbour jackets,barbour factory you will wait basketball shoes,cheap basketball shoes on this louis vuitton,louis vuitton outlet gentleman, who michael kors,michael kors is confined ferragamo,salvatore ferragamo to his bed by abercrombie and fitch,abercrombie fitch an longchamp,longchamp taschen accident, hilfiger,tommy hilfiger exactly prada handbags,prada sunglasses as lululemon,lululemon canada you iphone cases,iphone case would ralph lauren outlet online,polo ralph lauren outlet online wait on roshe runs,roshe run me timberland boots,timberland shoes if I were nike,nike.se ill. longchamp handbags,longchamp outlet If we christian louboutin,christian louboutin shoes both tommy hilfiger,hilfiger online shop happen moncler outlet,moncler outlet online to mcm bags,mcm handbags ring for you cheap shoes,boots on sale together, reebok,reebok you michael kors bags,michael kors outlet online sale will moncler jackets,moncler mens jackets answer abercrombie and fitch,abercrombie his bell handbags outlet,purses and handbags before hollister clothing,hollister clothing store you answer mine. nike roshe,roshe run The usual changes of linen are, of course, michael kors outlet online,michael kors bags ready air force,nike air force in louis vuitton bags,louis vuitton purses the wardrobe there? gucci,gucci Very gucci mens shoes,gucci belts good. Go prada shoes,prada outlet now, and tell vuitton handbags,louis vuitton handbags the adidas shoes,adidas online cook air max,nike air max to ray ban,rayban prepare a little dinner; nike air,air max and replica watches,rolex watches get a wedding dresses uk,wedding dresses bottle watches,watches canada of nike free 5.0,free running the old Madeira michael kors purses,michael kors handbags out of the cellar. tiffany and co,tiffany and co australia You soccer shoes,indoor soccer shoes will ralph lauren,polo ralph least, in this room. air jordan shoes,jordan shoes These mont blanc pens,mont blanc two the north face outlet,north face jackets gentlemen will gucci belts,gucci handbags be horloges,rolex best abercrombie and fitch,abercrombie kids pleased beats by dre,beats headphones to dine swarovski jewelry,swarovski crystal together. Return here in north face outlet,the north face five minutes’ pandora,pandora time, air max,nike air max in gucci handbags,gucci outlet case you insanity workout,insanity workout calendar are asics,asics gel wanted; new balance shoes,new balance outlet and louboutin,christian louboutin show my guest, Peter, that I coach purses outlet,coach purses outlet online am right in believing you to be a relojes,reloj good beats by dre headphones,dre beats nurse as ralph lauren outlet,polo ralph well as softball bats,baseball bats a oakley,oakley good ray ban sunglasses outlet,ray ban wayfarer servant.”
The michael kors handbags clearance,michael kors outlet online silent uggs,uggs on sale and giuseppe shoes,giuseppe zanotti sneakers surly Peter ray ban wayfarer,cheap ray ban brightens under pandora jewellery,pandora the adidas,adidas superstar expression coach handbags,coach bags ocoach outlet online,coach outlet
Hi Dr. Murali,
The most common surgery for heart failure is bypass surgery to route blood around a blocked heart artery.