ИБС, стенокардия и СД

[Gilarov]

Олег Валентинович!
Рандомизация понятное дело не проводилась, по этическим соображениям.
ЗЫ: Если хотите кого-то процитировать, воспользуйтесь опциями через кнопку "Цитировать" или "послать ответ" (Или вручную введите "квадратная скобка"quote]фраза[/quote])

[Dr.Vad]

Уважаемый Олег Валентинович,

Рандомизации о которой мы привыкли говорить естественно не было (в свете текущих кардиогайдов ни один этич.комитет не даст добро о рандомизир. назначении и не-назначении ББ после ИМ), а была процедура подбора по основным факторам:

Matching
From the resulting sample (n = 1,246), 1,086 beta-blocker users and 160 non–beta-blocker users were identified. In order to make sure that the distribution of potentially confounding variables was equally distributed in the 2 groups, the subjects were matched using the frequency matching procedure on the following variables: hospital of admission, age (<60 or ≥60 years), gender (male/female), LVEF (<30% or ≥30%), and baseline depressive symptoms (Beck Depression Inventory [BDI] score <10 or ≥10) (22).

In order to enable a subgroup analysis based on beta-blocker dosage, beta-blocker users were over-represented by a factor 2. If one of the match variables was missing (n = 23), the subject was matched based on the available match variables. Subjects were excluded if more than 1 of the match variables was missing. If a non–beta-blocker user could not be matched with 2 beta-blocker users, the subject was excluded from the sample. Application of these criteria resulted in a final study sample of 127 non–beta-blocker users and 254 beta-blocker users, representing 30.6% of the total sample.

По рандомизир. назначению бета-блокеров и возникновению депрессии есть целый мета-анализ:

The 15 trials involved more than 35 000 subjects. B-Blocker therapy was not associated with a significant absolute annual increase in risk of reported depressive symptoms (6 per 1000 patients; 95% confidence interval [CI], –7 to 19). B-Blockers were associated with a small significant annual increase in risk of reported fatigue (18 per 1000 patients; 95% CI, 5-30), equivalent to 1 additional report of fatigue for every 57 patients treated per year with -blockers. B-Blockers were also associated with a small, significant annual increase in risk of reported sexual dysfunction (5 per 1000 patients; 95% CI, 2-8), equivalent to one additional report for every 199 patients treated per year. None of the risks of adverse effects differed significantly by degree of b-blocker lipid solubility. The risk associated with reported fatigue was significantly higher for early-generation than for late-generation -blockers (P = .04).

JAMA. 2002;288:351-357.

Вот фрагмент ред. комментария к первой публикации:

...we agree that the most important lesson to be learned from their study is to abandon the general reluctance in prescribing beta-blockers to post-MI patients who are depressed and do not have any absolute contraindication for this medication.

J Am Coll Cardiol. 2006 Dec 5;48(11):2215-7

[Dr.]

Сообщение от Dr.Vad

Да нет никакой депрессии от бета-блокеров, если по-нормальному запланировать исследование:

J Am Coll Cardiol. 2006 Dec 5;48(11):2209-14.

Beta-blockers and depression after myocardial infarction: a multicenter prospective study.
van Melle JP, Verbeek DE, van den Berg MP, Ormel J, van der Linde MR, de Jonge P.
Department of Cardiology, Thoraxcenter, University Medical Center Groningen, Groningen, The Netherlands.

OBJECTIVES: The purpose of this research was to explore the prospective relationship between the use of beta-blockers and depression in myocardial infarction (MI) patients. BACKGROUND: Beta-blocker use has been reported to be associated with the development of depression, but the methodological quality of studies in this field is weak. METHODS: In a multicenter study, MI patients (n = 127 non-beta-blocker users and n = 254 beta-blocker users) were assessed for depressive symptoms (using the Beck Depression Inventory [BDI] at baseline and t = 3, 6, and 12 months post-MI) and International Classification of Diseases-10 depressive disorder (Composite International Diagnostic Interview). Patients were matched using the frequency matching procedure according to age, gender, hospital of admission, presence of baseline depressive symptoms, and left ventricular function. RESULTS: No significant differences were found between non-beta-blocker users and beta-blocker users on the presence of depressive symptoms (p > 0.10 at any of the time points) or depressive disorder (p = 0.86). Controlling for confounders did not alter these findings. A trend toward increasing BDI scores was seen in patients with long-term use of beta-blockers and patients with higher beta-blocker dose. CONCLUSIONS: In post-MI patients, prescription of beta-blockers is not associated with an increase in depressive symptoms or depressive disorders in the first year after MI. However, long-term and high-dosage effects cannot be ruled out.

А если у кого после ИМ и разовьется, то имеется и соответствующее лечение.

Вот вопрос, можно ли после одного такого исследования с таким небольшим количеством человек, подвергать сомнению классическую точку зрения, что б-блокаторы примерно в 5% случаях при лечении гипертонической болезни, стенокардии и после инфаркта вызывают депрессию? Все апдейтнутые руководства, в т.ч. от AHFS, об этом пишут. Надо проработать сей вопрос

[ozinvev]

Уважаемые Михаил Юрьевич и Вадим Валерьевич,никто не оспаривает назначение в-блокаторов по жизненным показаниям (больным после ИМ - снижение АР до 5% ежегодно) при симптомах депрессии. Мы же рассматривали частный случай. И почему так не нравится мой любимый перцовый пластырь? Один раз налепят и выздоравливают (душой). Если же есть стенокардия - Вы же её услышите и, м.б., увидите. Мета-анализы я тоже люблю читать, но и о недостатках их тоже начитан. Спасибо, что не отказали в общении.
Ещё раз с уважением.
Олег Валентинович.

[Dr.]

Сообщение от ozinvev

Dr.:
2. Отвлекающая терапия при наличии болевого синдрома - почему плохо? Если шейку продует - попробуйте, можно и на колени.

Какого болевого синдрома? Стенокардии? Лечится не перцовым пластырем. Костохондрита? Тоже не перцовым пластрыем, есть способы лучше. Давайте все же не древние и хитрые способы на РМС описывать, а общепринятые. Шейки у меня нет, но если "продует" шею, обойдусь

P.S.

Сообщение от Викентий Вересаев. Записки врача

В лечении болезней меня поражала чрезвычайная шаткость и
неопределенность показаний, обилие предлагаемых против каждой болезни
средств - и рядом с этим крайняя неуверенность в действительности этих
средств. "Лечение аневризмы аорты, - говорится, на" пример, в руководстве
Штрюмпеля, - до сих пор дает еще очень сомнительные результаты; тем не
менее, в каждом данном случае мы вправе испробовать тот или другой из
рекомендованных способов". "Чтобы предотвратить повторение припадков грудной
жабы, - говорится там же, - рекомендовано очень много средств: мышьяк,
сернокислый цинк, азотнокислое серебро, бромистый калий, хинин и другие.
Попробовать какое-либо из этих средств не мешает, но верного успеха обещать
себе не следует"; и так без конца. "Можно попробовать то-то", "некоторые
очень довольны тем-то", "не мешает испытать то-то". Я пришел сюда, чтоб меня научили, как вылечить больного, а мне предлагают "пробовать", да еще без всякого ручательства за успех!

[ozinvev]

Сообщение от Dr.

Какого болевого синдрома? Стенокардии? Лечится не перцовым пластырем. Костохондрита? Тоже не перцовым пластрыем, есть способы лучше. Давайте все же не древние и хитрые способы на РМС описывать, а общепринятые. Шейки у меня нет, но если "продует" шею, обойдусь

P.S.

Я без заднего смысла про шею, просто ласково. Диагноза у нас ведь ещё нет. ИБС или "костохондрит" или депрессия. Согласен, дадим ибупрофен (спросив про язву). Разово или пока боль непройдет от "костохондрита"? А то жидкость задерживает. Или лучше дождемся результатов стресс-теста (если доведут до критериев).
С уважением.
Олег Валентинович.

[Gilarov]

Саш!
Если действительно интресует взаимосвязь депрессии и БАБ , я спрошу у наших психиатров, ибо они какой-то разбор про это писали (и вроде нет ее, депрессии этой).

[Delsol]

J Am Coll Cardiol. 2006 Dec 5;48(11):2215-7. Epub 2006 Nov 9.
Comment on:
J Am Coll Cardiol. 2006 Dec 5;48(11):2204-8.
J Am Coll Cardiol. 2006 Dec 5;48(11):2209-14.
Depression after myocardial infarction: unraveling the mystery of poor cardiovascular prognosis and role of beta-blocker therapy.von Kanel R, Begre S.
von Känel and Begré J Am Coll Cardiol.2006; 48: 2215-2217

[Ссылки доступны только зарегистрированным пользователям ]

J Am Coll Cardiol, 2006; 48:2209-2214, doi:10.1016/j.jacc.2006.07.056 (Published online 8 November 2006).
© 2006 by the American College of Cardiology Foundation
CLINICAL RESEARCH: MYOCARDIAL INFARCTION AND DEPRESSION
Beta-Blockers and Depression After Myocardial Infarction
A Multicenter Prospective Study
Joost P. van Melle, MD, PhD*,*, Daniëlle E.P. Verbeek, MD*, Maarten P. van den Berg, MD, PhD*, Johan Ormel, PhD, Marcel R. van der Linde, MD and Peter de Jonge, PhD
* Department of Cardiology, Thoraxcenter, University Medical Center Groningen, Groningen, the Netherlands
Department of Psychiatry, University Medical Center Groningen, Groningen, the Netherlands
Department of Cardiology, Nij Smellinghe Hospital, Drachten, the Netherlands.
[Ссылки доступны только зарегистрированным пользователям ]

Evidence-Based Medicine 2003; 8:15
© 2003 BMJ Publishing Group
Therapeutics
Review: ß blockers increase fatigue and sexual dysfunction but not depression after myocardial infarction
Ko DT, Hebert PR, Coffey CS, et al. [Ссылки доступны только зарегистрированным пользователям ]

ACP J Club. 2003 Jan-Feb;138(1):30; author reply 30.
Comment on:
ACP J Club. 2003 Jan-Feb;138(1):4.
Review: Beta-blockers increase fatigue and sexual dysfunction but not depression after myocardial infarction.Ko DT, Hebert PR, Krumholz HM.
[Ссылки доступны только зарегистрированным пользователям ]

JAMA. 2002;288:351–7
ß-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction.
Comment in:
ACP J Club. 2003 Jan-Feb;138(1):4.
J Fam Pract. 2002 Oct;51(10):814.
JAMA. 2002 Oct 16;288(15):1845-6; author reply 1846.
JAMA. 2002 Oct 16;288(15):1845; author reply 1846.
Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction.Ko DT, Hebert PR, Coffey CS, Sedrakyan A, Curtis JP, Krumholz HM.
[Ссылки доступны только зарегистрированным пользователям ]

Arch Intern Med. 2004 Jul 12;164(13):1389-94.
Comment in:
ACP J Club. 2005 Mar-Apr;142(2):36.
Arch Intern Med. 2004 Jul 12;164(13):1370-1.
Adverse effects of beta-blocker therapy for patients with heart failure: a quantitative overview of randomized trials.Ko DT, Hebert PR, Coffey CS, Curtis JP, Foody JM, Sedrakyan A, Krumholz HM.
[Ссылки доступны только зарегистрированным пользователям ]

JAMA Vol. 288 No. 15, October 16, 2002
-Blocker Therapy and Depression
[Ссылки доступны только зарегистрированным пользователям ]

JAMA. 2002;288:Vol. 288 No. 3, July 17, 351-357
CLINICIAN'S CORNER
-Blocker Therapy and Symptoms of Depression, Fatigue, and Sexual Dysfunction
Dennis T. Ko, MD; Patricia R. Hebert, PhD; Christopher S. Coffey, PhD; Artyom Sedrakyan, MD; Jeptha P. Curtis, MD; Harlan M. Krumholz, MD
[Ссылки доступны только зарегистрированным пользователям ]

[Dr.]

Сообщение от Gilarov

Саш!
Если действительно интресует взаимосвязь депрессии и БАБ , я спрошу у наших психиатров, ибо они какой-то разбор про это писали (и вроде нет ее, депрессии этой).

Интересует . Это ж не просто какой-то академический вопрос (на самом деле я не фанат диагностики и лечения депрессий, 7% гериатрической популяции ей страдает, а что говорить про больных людей)? Вон что товарищ 16-й Харрисон пишет:

CHOICE BETWEEN BETA BLOCKERS AND CALCIUM ANTAGONISTS FOR INITIAL THERAPY Since beta blockers have been shown to improve life expectancy following acute myocardial infarction (Chap. 228) while calcium antagonists have not, the former may also be preferable in patients with chronic IHD1. However, calcium antagonists are indicated in patients with the following: (1) inadequate responsiveness to the combination of beta blockers and nitrates; many such patients do well with a combination of a beta blocker and a dihydropyridine calcium antagonist; (2) adverse reactions to beta blockers such as depression, sexual disturbances, and fatigue; (3) angina and a history of asthma or chronic obstructive pulmonary disease; (4) sick-sinus syndrome or significant atrioventricular conduction disturbances; (5) Prinzmetal's angina; or

[Gilarov]

Sexual disturbance возникают у тех, кто прочел аннотацию...

[Dr.Vad]

Саша, посмотри какой год Харрисона: как правило книжки опаздывают на 4-5 лет от публикаций, поэтому даже в издании 2007 года еще не будет этого мета-анализа 2002 г (взято из сообщения Delsol 76):

[Ссылки доступны только зарегистрированным пользователям ]

[Dr.]

Сообщение от Dr.Vad

Саша, посмотри какой год Харрисона: как правило книжки опаздывают на 4-5 лет от публикаций, поэтому даже в издании 2007 года еще не будет этого мета-анализа 2002 г (взято из сообщения Delsol 76):

[Ссылки доступны только зарегистрированным пользователям ]

Я понимаю, что это уже старье, процитировал не как эвиденс, а как оправдание того, что мой интерес к депрессиям - не академический, а клинический . Иначе говоря, "не чтобы поспорить"

[Delsol]

J Am Coll Cardiol, 2006; 48:2209-2214, CLINICAL RESEARCH: MYOCARDIAL INFARCTION AND DEPRESSION
Beta-Blockers and Depression After Myocardial Infarction
A Multicenter Prospective Study
Netherlands.
CONCLUSIONS: In post-MI patients, prescription of beta-blockers is not associated with an increase in depressive symptoms or depressive disorders in the first year after MI. However, long-term and high-dosage effects cannot be ruled out.


Evidence-Based Medicine 2003; 8:15
Review: ß blockers increase fatigue and sexual dysfunction but not depression after myocardial infarction
CONCLUSIONS: In patients who have had myocardial infarction, hypertension, or heart failure, ß blockers increase fatigue and withdrawals because of fatigue or sexual dysfunction. ß blockers do not increase depressive symptoms.


JAMA. 2002;288:351-357.
CLINICIAN'S CORNER
ß-Blocker Therapy and Symptoms of Depression, Fatigue, and Sexual Dysfunction
CONCLUSION: The conventional wisdom that ß-blocker therapy is associated with substantial risks of depressive symptoms, fatigue, and sexual dysfunction is not supported by data from clinical trials. There is no significant increased risk of depressive symptoms and only small increased risks of fatigue and sexual dysfunction. The risks of these adverse effects should be put in the context of the documented benefits of these medications.


European Heart Journal Volume 27, Number 22 Pp. 2632-2639
Association between erectile dysfunction and coronary artery disease. Role of coronary clinical presentation and extent of coronary vessels involvement: the COBRA trial
CONCLUSION: Erectile dysfunction prevalence differs across subsets of patients with CAD and is related to coronary clinical presentation and extent of CAD. In patients with established CAD, ED comes before CAD in the majority by an average of 2 up to 3 years.


European Heart Journal Volume 27, Number 22 Pp. 2613-2614
Erectile dysfunction: a marker of silent coronary artery disease
Erectile dysfunction (ED) is common affecting over 50% of men aged 40–70 years.1 It increases with age so that men over 70 years (with a prevalence of 70%) have three times the incidence of men in their 40s. It is an important cause of relationships breaking down with the man losing self-esteem, feeling a failure, and the partner feeling rejected so that the man's problem becomes a couple's frustration and concern. With the development of the phosphodiesterase type 5 inhibitors has come a greater understanding of the mechanisms . . .


JAMA. 2006;295:2874-2881.
Depression and Cardiovascular Disease
Major depressive disorder is a risk factor for the development of incident coronary heart disease events in healthy patients and for adverse cardiovascular outcomes in patients with established heart disease. Depression is present in 1 of 5 outpatients with coronary heart disease and in 1 of 3 outpatients with congestive heart failure, yet the majority of cases are not recognized or appropriately treated. It is not known whether treating depression improves cardiovascular outcomes, but antidepressant treatment with selective serotonin reuptake inhibitors is generally safe, alleviates depression, and improves quality of life. This article evaluates the importance of major depression in patients with cardiovascular disease, and provides practical guidance for identifying and treating this disorder


Alan C Swann, MD
University Texas-Houston Medical School, Houston, Texas, USA :
ß noradrenergic antagonists have broad utility, but they are considered to have troublesome side effects. Ko et al found that ß blockers were associated with increased fatigue and increased withdrawal because of fatigue or sexual dysfunction. Yet, closer examination sheds doubt on whether the evidence supports differential effects across the 3 problems and raises questions about the interpretation of side effects in placebo controlled trials.

Both placebo and active drug effects ranged widely across studies and were strongly correlated (table 2). The range across studies dwarfed the relatively small apparent differences between placebo and active drug. The significant difference between placebo and active drug for withdrawal because of fatigue or sexual dysfunction may reflect a true adverse effect of ß blockers, although with sexual dysfunction the difference may not be meaningful because almost all withdrawals were in the same study.

The heterogeneity across trials, with close tracking of placebo and active drug effects, is consistent with a nocebo effect, whereby negative expectations can result in unfavorable outcomes.1 Side effects of placebo have been documented to resemble those of the reference drug.2 Patients in randomised clinical trials receive detailed information about potential side effects of the reference drug. This contributes to similar "side effect" rates for active drug and placebo but would not account for the wide range of event rates. Such a range could result from varying sources, including patient characteristics, actual ß blockers used, or study design.

In summary, a prominent apparent nocebo effect probably biases toward underdetection of side effects in placebo controlled trials. Furthermore, the studies were so heterogeneous in event rates that it is difficult to interpret their results in combination. Even with these biasing factors, differences in the incidence of fatigue and sexual dysfunction emerge.


J Clin Hypertens. 2005; 7 (5): 274-285.
Quality of Life and Antihypertensive Drug Therapy
Joel Handler, MD
A recent study examined the placebo effect related to erectile dysfunction and ß-blocker admin-istration.[24] When you think a pill is going to do you some good, many times it does. If you think a pill is going to do you some harm, many times it does. In this study, three groups of men were administered 50 mg of atenolol. In the first group, patients were not told that it was a bioactive drug, and erectile dysfunction was minimal over several months. In the second group, patients were told that they were being administered a ß blocker, and reports of erectile dysfunction significantly increased. The third group of men were told that they were being given a ß blocker and that they might experience erectile dysfunction and, again, erectile dysfunction significantly increased. The message given to patients may have an important effect on subsequent adverse effect reporting. There is no doubt that there are truly some cases of sexual dysfunction from the use of diuretics or ß blockers, but these are not as common as many have been led to believe.