The heart in septic shock and beta-blockade. Reconsidering the paradox?

Czech version

Authors: Matějovič Martin
Authors‘ workplace: Biomedicínské centrum, Lékařská fakulta v Plzni, Univerzita Karlova v Praze, Plzeň, Česká republika ; I. interní klinika, Lékařská fakulta v Plzni, Univerzita Karlova v Praze, Fakultní nemocnice Plzeň
Published in: Anest. intenziv. Med., 24, 2013, č. 6, s. 403-409
Category: Intesive Care Medicine - Special Article

Overview

Myocardial depression is a well-recognized consequence of septic shock. A growing body of evidence suggests that excessive catecholamine levels exert toxic effects on the heart, thereby contributing to the development of septic myocardial dysfunction. Although seemingly counter-intuitive, beta-blockade aimed at the attenuation of the sympatho-adrenergic stress may represent a plausible concept in protecting the heart during septic shock. Limited experimental and clinical evidence indicates that careful control of heart rate using short-acting beta-1 selective blockers might economize cardiac work without exerting adverse systemic haemodynamiceffects in septic subjects. Rigorous testing of this concept in randomized clinical trials is needed before it can be implemented in clinical practice. This article briefly introduces the concept of de-catecholaminisation and discusses the pros and cons of this emerging paradigm.

Keywords:
septic shock – beta-blockade – esmolol – hemodynamics – heart failure

Sources

1. Rudiger, A., Singer, M. The heart in sepsis: from basic mechanisms to clinical management. Curr. Vasc. Pharmacol., 2013, 11, 2, p. 187–195.

2. Chvojka, J., Matějovič, M. Srdce u nemocných v sepsi – septická kardiomyopatie. Postgrad. Med., 2012, 10, p. 12–18.

3. Park, J. H., Kang, S. J., Song, J. K., Kim, H. K., Lim, C. M., Kang, D. H., Koh, Y. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest, 2005, 128, 1, p. 296–302.

4. Balik, M., Rulisek, J., Leden, P., Zakharchenko, M., Otahal, M., Bartakova, H., Korinek, J. Concomitant use of beta-1 adrenoreceptor blocker and norepinephrine in patients with septic shock. Wien Klin Wochenschr., 2012, 124, 15–16, p. 552–556.

5. Suzuki, T., Morisaki, H., Serita, R., Yamamoto, M., Kotake, Y., Ishizaka, A., Takeda, J. Infusion of the beta-adrenergic blocker esmolol attenuates myocardial dysfunction in septic rats. Crit. Care Med., 2005, 33, 10, p. 2294–2301.

6. Hagiwara, S., Iwasaka, H., Maeda, H., Noguchi, T. Landiolol, an ultrashort-acting beta1-adrenoceptor antagonist, has protective effects in an LPS-induced systemic inflammation model. Shock, 2009, 31, 5, p. 515–520.

7. Ackland, G. L., Yao, S. T., Rudiger, A., Dyson, A., Stidwill, R., Poputnikov, D., Singer, M., Gourine, A. V. Cardioprotection, attenuated systemic inflammation, and survival benefit of beta1-adrenoceptor blockade in severe sepsis in rats. Crit. Care Med., 2010 38, 2, p. 388–394.

8. Aboab, J., Sebille, V., Jourdain, M., Mangalaboyi, J., Gharbi, M.,Mansart, A., Annane, D. Effects of esmolol on systemic and pulmonary hemodynamics and on oxygenation in pigs with hypodynamic endotoxin shock. Intensive Care Med., 2011 37, 8, p. 1344–1351.

9. Schmitz, D., Wilsenack, K., Lendemanns, S., Schedlowski, M., Oberbeck, R. Beta-Adrenergic blockade during systemic inflammation: impact on cellular immune functions and survival in a murine model of sepsis. Resuscitation, 2007, 72, 2, p. 286–294.

10. Gore, D. C., Wolfe, R. R. Hemodynamic and metabolic effects of selective beta1 adrenergic blockade during sepsis. Surgery, 2006, 139, 5, p. 686–694.

11. Schmittinger, C. A., Dünser, M. W., Haller, M., Ulmer, H., Luckner, G., Torgersen, C., Jochberger, S., Hasibeder, W. R. Combined milrinone and enteral metoprolol therapy in patients with septic myocardial depression. Crit. Care, 2008, 12, 4, p. R99.

12. Novotny, N. M., Lahm, T., Markel, T. A., Crisostomo, P. R., Wang, M., Wang, Y., Ray, R., Tan, J., Al-Azzawi, D., Meldrum, D. R. Beta-blockers in sepsis: reexamining the evidence. Shock, 2009, 31, p. 113–119.

13. Rudiger, A. Beta-block the septic heart. Crit. Care Med., 2010, 38, p. S608–S612.

14. de Montmollin, E., Aboab, J., Mansart, A., Annane, D. Bench--to-bedside review: Beta-adrenergic modulation in sepsis. Crit. Care, 2009, 13, p. 230.

15. Morelli, A., Ertmer, C., Westphal, M., Rehberg, S., Kampmeier, T., Ligges, S., Orecchioni, A., D’Egidio, A., D’Ippoliti, F., Raffone, C., Venditti, M., Guarracino, F., Girardis, M., Tritapepe, L., Pietropaoli, P., Mebazaa, A., Singer, M. Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock: A Randomized Clinical Trial. JAMA, 2013, Oct 9. doi: 10.1001/jama.2013.278477.

16. Morelli, A., Donati, A., Ertmer, C., Rehberg, S., Kampmeier, T., Orecchioni, A., D’Egidio, A., Cecchini, V., Landoni, G., Pietropaoli, P., Westphal, M., Venditti, M., Mebazaa, A., Singer, M.Microvascular effects of heart rate control with esmolol inpatients with septic shock: a pilot study. Crit. Care Med., 2013, 41, 9, p. 2162–218.

17. Chertow, G. M., Palevsky, P. M., Greene, T. Studying the prevention of acute kidney injury: lessons from an 18th-century mathematician. Clin. J. Am. Soc. Nephrol., 2006, 1, 5, p. 1124–1127.

18. Sander, O., Welters, I. D., Foëx, P., Sear, J. W. Impact of prolonged elevated heart rate on incidence of major cardiac events in critically ill patients with a high risk of cardiac complications. Crit. Care Med., 2005, 33, 1, p. 81–88.

19. POISE Study Group, Devereaux, P. J., Yang, H., Yusuf, S., Guyatt, G., Leslie, K., Villar, J. C., Xavier, D., Chrolavicius, S., Greenspan, L., Pogue, J., Pais, P., Liu, L., Xu, S., Málaga, G., Avezum, A., Chan, M., Montori, V. M., Jacka, M., Choi, P. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet, 2008, 371, 9627, p. 1839–1847.

20. Chen, Z. M., Pan, H. C., Chen, Y. P., Peto, R., Collins, R., Jiang, L. X., Xie, J. X., Liu, L. S.; COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet, 2005, 5, 366, 9497, p. 1622–1632.

21. Macchia, A., Romero, M., Comignani, P. D., Mariani, J., D’Ettorre, A., Prini, N., Santopinto, M., Tognoni, G. Previous prescription of β-blockers is associated with reduced mortality among patients hospitalized in intensive care units for sepsis. Crit. Care Med., 2012, 40, 10, p. 2768–2772.

22. Christensen, S., Johansen, M. B., Tønnesen, E., Larsson, A., Pedersen, L., Lemeshow, S., Sørensen, H. T. Preadmission beta-blocker use and 30-day mortality among patients in intensive care: a cohort study. Crit. Care, 2011, 15, 2, p. R87.

23. Cvachovec, K. Beta-blockers in flow of time – view of an anaesthesiologist and intensivist. Cas. Lek. Cesk., 2010, 149, 6, p. 288–290.

24. Magder, S. A. The ups and downs of heart rate. Crit. Care Med., 2012, 40, 1, p. 239–245.

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Article was published in

Anaesthesiology and Intensive Care Medicine

2013 Issue 6