1) The document summarizes a study on the effects of adding bisoprolol to treatment regimens for patients with stage C systolic heart failure.
2) 30 patients receiving ACE inhibitors and furosemide had their ejection fraction and quality of life assessed before and 3 months after adding bisoprolol.
3) The results showed significant improvements in both ejection fraction and quality of life scores after adding bisoprolol to the treatment regimen.
6. Cardiovascular Stage C Systolic Heart Bisoprolol
Ambulatory Clinic Failure Patients
Added on
Checked
“baseline”
Ejection Fraction
17 & Quality of Life
13 Questionnaire
40-80 Years of Age (n=30) score
Dr Saiful Anwar Receiving Combination of
General Hospital ACE Inhibitor & Furosemide
3 months Followed up
Checked “endpoint” Ejection Fraction & Quality of
Life Questionnaire score
Quasi-experimental study used a one group pretest-posttest design
7. Stage C chronic & stable heart
failure
Had Ejection Fraction reduction (EF
< 50%)
Receiving optimum dose of ACE
inhibitor and furosemide
Fulfill for Bisoprolol indication
8. Acute heart failure and needed
Already accepted Bisoprolol
positive inotropic except
before recruitment
digoxin
Comorbid condition which
affect to quality of life such as Bradycardia (heart rate below
mitral regurgitation, atrial 60 times per minute)
fibrilation, & cardiogenic shock
Hypotension with systolic
Severe asthma
pressure below 100 mmHg
9. Simpson method
of measurement
Measured by two as a gold standard
experts in
operating
Echocardiography
10. 21 questions each
Minessota
Living with contained 6 choice
Heart Failure answers based on the
Questionnaire symptom frequencies
The worse heart failure The more frequent
condition & the higher symptoms the higher
impact on QOL questionnaire score
11. Mean Mean Mean Mean
Baseline Endpoint
Baseline Endpoint MLHFQ MLHFQ
EF EF score score
Comparison method:
Gaussian distribution pair t-test analysis
Non-Gaussian distribution Wilcoxon analysis
12. Inclusion &
February -
Subjects exclusion
October Eligible 30 subjects
recruitment criteria
2011
screening
Age
Comorbid
Sex Chi-Square
disease
Analysis
EF & QOL
13. Percentage (%) P value
Sex:
Male 73.3 0.465
Female 26,7
Age: P > 0.05 No
40 to 50 years old 13.3 significant
51 to 60 years old 30 0.141 contribution
61 to 70 years old 40 between those
71 to 80 years old 16,7 factors to EF or
QOL
History of previous illness:
Hypertension 26.7
0.061
Ischemic heart disease + HT 53.3
Diabetes Mellitus + HT 20
14. Mean EF did not meet
Mean Ejection Fraction Percentage
45
Gaussian Distribution
40
35
30
Non-parametric test
25
comparison
(%)
20 Baseline
15
3rd months
10 One group pretest-
5 posttest design
0
Baseline 3rd months
Time of Measurements (before & after Bisoprolol Wilcoxon analysis
Addition)
EF percentage (%) P value
Mean baseline 35.20 ± 8.98
0.000
Mean at 3rd months 42.80 ± 10.15
15. Mean QOL Questionnaire Score
Mean QOL questionnaire score
56
met Gaussian Distribution
54
52
Parametric test comparison
50
Baseline
48
3rd months
46 One group pretest-posttest
design
44
Baseline 3rd months
Time of Measurements (before & after Paired t test analysis
Bisoprolol Addition)
Mean QOL Questionnaire Score P value
Mean baseline 54.93 ± 9.61
0.000
Mean at 3rd months
16. Cardiac oxygen
ischemic-related QOL
demand
symptoms relieve improvement
reduction
Decrease
heart rate Increase cardiac output by
increasing stroke volume
though heart rate decline
Adequate
filling &
loading time Increase Ejection Fraction by
Bisoprolol reduce blood volume which
left in the ventricle
Inhibit Aldosterone
Decrease water & Cardiac load
renin antagonistic
sodium retention reduction
release effect
No ISA high effect on HR
reduction Slow down HF-related
No MSA minimum effect cardiomyopathy progression
on cardiac conductance
Editor's Notes
Good afternoon ladies & gentlemen..AssalamualaikumFor the first let me introduce my self. My name is EftaTriastuti, I am a lecturer in study program of pharmacy, faculty of medicine, Brawijaya university, Malang, Indonesia Secondly, I am very grateful to all of you for being here and listening to my research presentation entitled “role of bisoprolol addition on angiotensin converting enzyme inhibitor and furosemide combination on the left ventricular function in systolic HF patients”.
HF can be defined as clinical syndromes which are caused by the impairment of heart function and related to various kind of heart diseases.HF syndrome may lead to the reduction of QOL with high morbidity and mortality rate
Therapeutic guideline of heart failure from american heart association (AHA), Scottish Intercollegiate Guidelines Network (SIGN), and National Institute for Health and Clinical Excellence (NICE). Based on the result from several studies such as The Cardiac Insufficiency Bisoprolol Study (CIBIS),ß-Blocker Evaluation of Survival Trial (BEST), MetoprololRandomised Intervention Trial in congestive heart failure (MERIT-HF), Study of the Effects of Nebivolol Intervention on Outcomes and Rehospitalisation in Seniors with Heart Failure (SENIORS) and Carvedilol Prospective Randomized Cumulative Survival trial (COPERNICUS) Recommend the routinely use of beta blocker for stable heart failure patients. Which found that beta blocker brought many benefits in QOL, morbidity and mortality if given to stable heart failure patients.Bisoprolol, carvedilol or nebivolol should be the beta blocker of first choice for the treatment of patients with chronic heart failure due to left ventricular systolic dysfunction.
Beta blocker play role on the surge beta adrenergic activity in HF by block this activity will provide the reduction effect of excess beta adrenergic activity such as vasocontriction, sodium and water retention which lead to increase cardiac load and aggravate hypoperfusion due to inadequate ventricular ejectionOne of beta blocker which is recommended as the first choice therapy in stable HF is bisoprolol.This agent is available in IndonesiaThis agent has many benefits such as high affinity on beta one receptor that will bring lower risk of bronchospasm. This agent also does not have intrinsic sympathomimetic activity that will cause the more reduction in HR and provide the more adequate filling and loading time of left ventricle. Bisoprolol has no membrane stability activity that will provide the minimum effect on the cardiac conductance.
The aim of this study is to analyze the addition effect of bisoprolol on the optimum combination of ACE inhibitor & furosemide in systolic HF primarily in left ventricular function which affect to the QOL and the reduction of EF
This was quasi-experimental study used a one group pretest-posttest design.Research was conducted in cardiovascular ambulatory clinic of Dr. Saiful Anwar General Hospital Malang, Indonesia between february 2011 to january 2012. 13 women and 17 men with stage C systolic heart failure who receiving an optimum combinatio of ACE inhibitor and furosemide were recruited Bisoprolol was added on after baseline EF by echocardiography & QOL by Minessota Living with Heart Failure questionnaire measurementThen followed up for 3 monthsAnd checked end point EF & QOL
Inclusion criteria for patient recruitment were:Stage C chronic & stable HFHad EF reductionReceiving optimum combination dose of ACE inhibitor & furosmideFulfill for bisoprolol indication
Whereas exclusion criteria were:already accepted bisoprolol before recruitmentAcute HF & needed positive inotropic except digoxinComorbid condition which affect to QOL such as MR, AF & cardiogenic shockBradycardia with HR below 60 x per minuteHypotension with systolic pressure below 100 milimeterof mercurySevere asthma
Ejection fraction was measured by 2 expert in operating echocardiography with Simpson method as a gold standard.This method measures the ventricular volume in the end of diastolic phase and systolic phaseThe volume of end diastolic & systolic phase are being used to calculate the EF with this formula
While QOL measured by Minnesota Living with HF questionnaire which contain of 21 questions & each question contained 6 choice answers based on the symptom frequenciesThe more frequent symptoms resulted in the higher questionnaire scoreIt’s mean the worse heart failure condition & the higher impact on QOL
Statistical analysis in this study is to compare mean baseline EF to mean endpoint EF and mean baseline MLHFQ score to mean endpoint MLHFQ score.If the data following Gaussian distribution then the comparison method used pair t test analysisWhile non-Gaussian distribution data were analyzed by Wilcoxon test
Subjects recruitment was held on February to October 2011 & then we conducted sample screening to meet the inclusion & exclusion criteria, recruited subjects with a good adherence only found 30 patients.Comorbid disease, age, & sex were confounding factors that might have contribution to EF & QOLTherefore should be test the contribution by chi-square analysis
Chi-square analysis resulted that between sex, age, & history of previous illness had no significant contribution to EF & QOL showed with the P value more than 0.05
The bar charts between mean EF percentage versus time of measurements (before & after Bisoprolol addition) showed the mean baseline EF with the red color & mean endpoint EF with blue color.The mean EF did not meet Gaussian distribution, therefore we conducted non-parametric test comparison in one group pretest-posttest design using Wilcoxon analysisWilcoxon test for EF showed that there was significantly difference between baseline EF & endpoint EF with P value lest than 0.000
The bar charts between mean QOL questionnaire score versus time of measurements (before & after Bisoprolol addition) showed the mean baseline QOL questionnaire score with the green color & mean endpoint QOL questionnaire score with orange color.The mean QOL questionnaire score met Gaussian distribution, therefore we conducted parametric test comparison in one group pretest-posttest design using paired t test analysisPaired t test for QOL questionnaire score showed that there was significantly difference between baseline & endpoint QOL questionnaire score with P value lest than 0.000
From this results we discussed that the characteristic of bisoprolol in ISA provide the high effect on HR reduction and bisoprolol characteristic in MSA provide the minimum effect on cardiac conductance.Bisoprolol act to decrease HR which provide Cardiac oxygen demand reduction that relieve ischemic-related symptoms & provide QOL improvement, besides the reduction of HR might provide Adequate filling & loading time which resulted in Increase cardiac output by increasing stroke volume though heart rate decline & Increase Ejection Fraction by reduce blood volume which left in the left ventricle.Bisoprolol also has a role to inhibit renin release which might provide Aldosterone antagonistic effect & caused Decrease water & sodium retention that brought to the Cardiac load reduction & Slow down HF-related cardiomyopathy progression
Based on the result we might conclude that This prospective study showed that the routine addition of Bisoprolol to ACE inhibitor and furosemide combination may significantly improve ejection fraction and quality of life in systolic heart failure patients (each by P = 0.000; 95% confidence of interval)
This is the end of my presentation. Thank you very much