Carvedilol compared with metoprolol on left ventricular ejection fraction after coronary artery bypass graft
on Left Ventricular Ejection Fraction After
Mehran Shahzamani, MD, Arash Ghanavati, MD, Azam Nouri Froutagheh, RN,
Mahnoosh Foroughi, MD, Hosein Rahimian, MD, Azadeh Shahsanaei, MD,
Seyed Ahmad Hasantash, MD, Ali Dabbagh, MD
A number of elective coronary artery bypass graft (CABG) surgerypatients have impaired underlying left ventricular function (poor ejec-tion fraction). This study was performed to compare the effect of postop-erative oral carvedilol versus metoprolol on left ventricular ejectionfraction (LVEF) after CABG compared with metoprolol. In a double-blind clinical trial, 60 patients with coronary artery disease, aged 35 to65 years, who had an ejection fraction of 15% to 35% were included.
Either carvedilol or metoprolol was administered the day after CABG.
The patients were evaluated by the same cardiologist 14 days beforeand 2 and 6 months after elective CABG. The results demonstrated betterimprovements in LVEF in the carvedilol group. No difference regardingpostoperative arrhythmias or mortality was detected. The results suggestthat carvedilol may exert more of an improved myocardial effect than me-toprolol for the low ejection fraction patients undergoing CABG in theearly postoperative months.
Keywords: carvedilol, metoprolol, coronary artery bypass graft surgery.
Ó 2011 by American Society of PeriAnesthesia Nurses
A NUMBER OF elective coronary artery bypass
do not improve left ventricular ejection fraction
graft (CABG) surgery patients have impaired under-
(LVEF) more than 10%.Repeated hospitalizations
lying left ventricular function (poor ejection frac-
are a frequent problem during the postoperative
tion [EF])After CABG, these patients typically
months, primarily because of preexisting heart
Mehran Shahzamani, MD, Fellowship in Cardiac Surgery,
kord, Iran; Seyed Ahmad Hasantash, MD, Fellowship in
Assistant Professor, Department of Cardiac Surgery, Shahid Be-
Cardiac Surgery, Professor, Department of Cardiac Surgery,
heshti University of Medicine, Tehran, Iran; Arash Ghanavati,
Shahid Beheshti University of Medicine, Tehran, Iran; and
MD, Fellowship in Cardiac Surgery, Assistant Professor, Depart-
Ali Dabbagh, MD, Fellowship in Cardiac Anesthesiology, Asso-
ment of Cardiac Surgery, Shahid Beheshti University of Medi-
ciate Professor, Anesthesiology Research Center and Anesthesi-
cine, Tehran, Iran; Azam Nouri Froutagheh, RN, Research
ology Department, Shahid Beheshti University of Medical
Development Department, Modarres Hospital, Shahid Be-
heshti University of Medical Sciences, Tehran, Iran; Mahnoosh
Conflict of interest: None to report.
Foroughi, MD, Fellowship in Cardiac Surgery, Assistant Profes-
Address correspondence to Ali Dabbagh, Anesthesiology Re-
sor, Department of Cardiac Surgery, Shahid Beheshti Univer-
search Center, Shahid Beheshti University of Medical Sciences,
sity of Medical Sciences, Tehran, Iran; Hosein Rahimian, MD,
Fellowship in Cardiac Surgery, Department of Cardiac Surgery,
Ó 2011 by American Society of PeriAnesthesia Nurses
Modarres Hospital, Shahid Beheshti University of Medical
Sciences, Tehran, Iran; Azadeh Shahsanaei, MD, Research
Deputy, Shahrekord University of Medical Sciences, Shahre-
Journal of PeriAnesthesia Nursing, Vol 26, No 6 (December), 2011: pp 384-387
failure. This preexisting heart failure leads to in-
evidence of atrioventricular block or severe
creased postoperative mortality and morbidity
sinoatrial node dysfunction, according to
b-adrenergic blockers have been shown to decrease
any contraindications for administration of
the mortality and morbidity of heart failure pa-
tientCarvedilol, a nonselective third-generation
The patients were assigned randomly into one of
adrenergic blocker, is more effective than otherb
two study groups using a computer table of ran-
-adrenergic blocking agents, especially in patients
dom numbers for random allocation. The first
group (group 1), which included 30 patients,
(MI)This study was designed and performed to
received oral carvedilol, and the second group
compare the effect of postoperative oral carvedilol
(group 2), also including 30 patients, received
versus oral metoprolol on increasing EF after CABG.
oral metoprolol tartrate. Both groups receivedthe drugs after elective CABG.
All the patients underwent echocardiography dur-
This research study received approval from the
ing 14 preoperative days before the surgical opera-
Institutional Review Board Committee for Ethical
tion and again at 2 and 6 months after CABG.
Considerations, Research Deputy, Shahid Beheshti
The echocardiography examination was again
University of Medical Sciences, Tehran, Iran.
performed by the same cardiologist and echocardio-
The research project was accomplished during
graphic machine (GE Vingmed Vivid 5 Echocardiog-
a 24-month period from January 2008 through
raphy System; All Imaging Systems, Inc., Irvine, CA)
December 2009. Patients gave written informed
in the same hospital. During the postoperative
consent before enrollment in the study.
period, the patients were evaluated regarding atrialarrhythmias and 1-month mortality.
In a prospective randomized double-blind clinicaltrial, 60 patients with coronary artery disease
Conventional on-pump CABG was performed in all
were enrolled. The study included 22 women
60 patients. After establishing cardiopulmonary
and 38 men, whose ages ranged from 35 to 65
bypass, mild hypothermia (32C, passive cooling)
years and who had an EF of 15% to 35%. The EF
was used, with crystalloid cardioplegia solution.
was confirmed by the same cardiologist during
The b-blocker drugs were begun the day after the
operation. Low-dose oral carvedilol (3.125 mg)twice daily was started for the first group. If the
The patients also each had a history of recent MI.
patient tolerated the drug, the dose was gradually
The MI had occurred more than 4 weeks before
increased over 2 weeks to reach a maximum of
the study and was documented by electrocardio-
12.5 mg twice daily. Low-dose oral metoprolol tar-
graphic (ECG) and dipyridamole-thallium imaging
trate (50 mg/day) was used for the second group
results. Those patients who had a recent MI during
by the same pattern of administration. If the pa-
the last 4 weeks were excluded because those who
tient tolerated the drug, the dose was gradually
have had a recent MI within 4 weeks are not usu-
increased over 2 weeks to reach a maximum
ally considered appropriate candidates for elective
of 200 mg twice daily to reach a maximum of
CABG. Viability of the myocardium was deter-
400 mg per day. These doses are comparing equi-
mined by single-photon emission computed to-
potent dosages of the two drugs. For both drugs,
mography (SPECT) and stress echocardiography.
the signs of intolerance that were critical markerswere intolerable fatigue, sinus bradycardia with
Those patients older than 65 or younger than
a heart rate of less than 45 per minute, and
35 years were excluded from the study. Also, the fol-
shortness of breath. If any of these occurred with
lowing items were considered as exclusion criteria:
drug administration, the drug would be discontin-
ued and the patient would be excluded from the
history of recent MI during the last 4 weeks
study. Fortunately, none of the patients had any
signs or symptoms of intolerance in any of the two
There was only one death in the second group (me-
toprolol group), which occurred in the fifth post-operative day after a cerebral vascular accident.
These medications were controlled to preventtheir effect on the myocardial function: digoxin,
Both groups had increased performance of the left
ventricle as demonstrated in their EF of the left
diuretics. No other variables with a possibility for
ventricle (LVEF), 2 and 6 months after CABG,
affecting the myocardial function were considered
when compared with their preoperative echocar-
necessary to be controlled and monitored. This is
diography assessments. In group 1 (ie, carvedilol),
EF was increased from baseline values to higherranges in the assessments performed at 2- and
6-month periods. In group 2 (ie, metoprolol), theEF had a similar pattern. The improvements in
The study data were recorded and extracted from
LVEF were significantly increased in group 1 (car-
each patient’s data sheet. Statistical analysis was
vedilol group) compared with group 2 (metopro-
performed using SPSS (version 11.5; SPSS Inc,
Chicago, IL). For statistical data analysis, Student
had no significant difference regarding functional
t test, chi-square test, and analysis of variance
status assessed by the New York Heart Association
were used. A value for P less than .05 was consid-
classification, 6 months after the operation.
Although bradycardia was more common in the
carvedilol group (three patients versus one pa-tient), the incidence of other arrhythmias (atrial
The two groups had no statistically significant dif-
fibrillation [AF] or flutter, premature atrial beats,
ference regarding age and the number of coronary
or premature ventricular contractions) was not
grafts in the operation (There were no dif-
significantly different. No difference may have
ferences between the two groups regarding gender
or in the incidence of diabetes mellitus, hyperlipid-emia, hypertension, previous history of MI, smok-
ing, and preoperative arrhythmias (P value for allthe variables greater than .05). The two groups
The study demonstrated an increase in LVEF in carve-
did not differ regarding their medications, includ-
dilol group. The study suggests that carvedilol is
ing digoxin, angiotensin-converting enzyme inhib-
more effective in patients than metoprolol to in-
crease EF after CABG. EF may rise 5% to 10% afterCABG surgery, however, in this study, the assess-
The results also demonstrated that there was no
ments performed after 6 months demonstrated that
difference regarding lengths of surgery, pump
the increase was greater than 10% in both groups.
run, intensive care unit stay, and hospitalization be-
The carvedilol group increased approximately
tween the two groups. All CABG operations were
18%. Much of this increase occurred during the first
LVEF, left ventricular ejection fraction; CABG, coro-
Figures are demonstrated as mean 6 standard
Figures are demonstrated as mean 6 standard deviation.
2 months after CABG, and this increase continued
postoperative period after landiolol administration.
Landiolol was not assessed in our study; but in otherstudies, landiolol has demonstrated an enhanced
In a 2005 study that looked at LVEF after CABG in
protective effect against tachycardia during AF in
20 patients with chronic hibernated myocardium
post-CABG patientAnother study demonstrated
studied before and after revascularization, the ef-
that in post-CABG patients, therapeutic landiolol in
fect of carvedilol on hibernating myocardium was
‘‘low doses’’ can decrease the prevalence of AF.
significantly better than that of metoprolol. The
However, our study did not demonstrate any differ-
authors of the study described their finding related
ence regarding the incidence or prevalence of
‘‘partially’’ to the ‘‘reduced cardiomyocyte degener-
arrhythmias or postoperative 6-month mortality.
ation’’ after carvedilol administration.All our
These issues differed from previous research, but
patients had a history of previous MI that was evi-
the results of this study could demonstrate the
denced by ECG, stress echocardiography, or SPECT,
effect of carvedilol on LVEF to be superior to
but the patients in the above study had hibernating
metoprolol, a therapeutic effect of the drug that
myocardium that would be accompanied with
could be because of its effects as a counteradrener-
a better response to revascularization, and the
gic agenTherefore, it would demonstrate this
sample size was smaller than that in our study.
effect as better performance on the poorlyfunctioning myocardium during the early post-
Carvedilol was demonstrated to produce better
effects on the performance of the LVEF thanmetoprolol (with equal doses), especially when
prescribed long The difference in patientmortality after metoprolol and carvedilol adminis-
Carvedilol could improve LVEF in the early postop-
tration is due to the greater counteradrenergic
erative period after CABG. When compared with
properties of carvedilol. Both drugs are b-blocking
metoprolol in patients with low EF, the patients
agents, but it is only carvedilol that is both a nonse-
demonstrate better early postoperative perfor-
lective b-blocker and also an a-1 blockerTo
mance of left ventricle. Evaluating patients with
strengthen these findings, other studies have as-
at least 1-year follow-up is recommended to assess
sessed the effects of carvedilol when used in the
the long-term outcome of such cases.
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Radiology Exam Report Patient Name: DOWNING, EDWARD KENT MRN: 223175 DOB/Age/Sex: 6/15/1935 75 Years Male FIN: 1022200107 Location: Outpatient// Patient Type: Outpatient One Time (ROP) Exam: VR Office Visit - New Patient Accession No: VR-10-0004907 Exam Status: Completed Exam Date/Time: 8/10/2010 14:51 Transcriptionist: Payne MD, Cynthia Ordering Physician: Mikles
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