고혈압 (hypertension), Inappropriate sinus tachycardia, 베타차단제 (beta blocker)

고혈압 약제 선택시 ARB를 많이 처방하는 편이고 다른 곳에서 약제를 처방 받아 온 환자들도 ARB가 많기는 합니다.

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베타차단제는 다음과 같은 경우 처방을 해야하는 약제이지만

Beta blockers — A beta blocker without intrinsic sympathomimetic activity should be given after an acute myocardial infarction and to stable patients with heart failure or asymptomatic left ventricular dysfunction (beginning with very low doses to minimize the risk and degree of initial worsening of myocardial function). The use of beta blockers in these settings is in addition to the recommendations for ACE inhibitors in these disorders.

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Beta blockers are also given for rate control in patients with atrial fibrillation, for control of angina, and for symptom control in a number of other disorders.

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다음과 같은 이유로 특별한 적응증이 없다면 베타차단제를 첫 약제로 사용하지 말 것을 권고합니다.

In the absence of such indications, we and others (including the 2014 statement from the American Society of Hypertension and the International Society of Hypertension) recommend that beta blockers not be used as first-line therapy, particularly in patients over age 60 years. Compared with other antihypertensive drugs in the primary treatment of hypertension, beta blockers (not all trials used atenolol) may be associated with inferior protection against stroke risk (particularly among smokers), and perhaps, with atenolol, a small increase in mortality. These effects are primarily seen in patients over age 60 years. Beta blockers are also associated with impaired glucose tolerance and an increased risk of new onset diabetes, with the exception of vasodilating beta blockers such as carvedilol and nebivolol.

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Considerations for individualizing antihypertensive therapy

Indication or contraindication	Antihypertensive drugs
Compelling indications (major improvement in outcome independent of blood pressure)
Heart failure with reduced ejection fraction	ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist*
Postmyocardial infarction	ACE inhibitor or ARB, beta blocker, aldosterone antagonist
Proteinuric chronic kidney disease	ACE inhibitor or ARB
Angina pectoris	Beta blocker, calcium channel blocker
Atrial fibrillation rate control	Beta blocker, nondihydropyridine calcium channel blocker
Atrial flutter rate control	Beta blocker, nondihydropyridine calcium channel blocker
Likely to have a favorable effect on symptoms in comorbid conditions
Benign prostatic hyperplasia	Alpha blocker
Essential tremor	Beta blocker (noncardioselective)
Hyperthyroidism	Beta blocker
Migraine	Beta blocker, calcium channel blocker
Osteoporosis	Thiazide diuretic
Raynaud phenomenon	Dihydropyridine calcium channel blocker
Contraindications
Angioedema	Do not use an ACE inhibitor
Bronchospastic disease	Do not use a non-selective beta blocker
Liver disease	Do not use methyldopa
Pregnancy (or at risk for)	Do not use an ACE inhibitor, ARB, or renin inhibitor (eg, aliskiren)
Second- or third-degree heart block	Do not use a beta blocker, nondihydropyridine calcium channel blocker unless a functioning ventricular pacemaker
Drug classes that may have adverse effects on comorbid conditions
Depression	Generally avoid beta blocker, central alpha-2 agonist
Gout	Generally avoid loop or thiazide diuretic
Hyperkalemia	Generally avoid aldosterone antagonist, ACE inhibitor, ARB, renin inhibitor
Hyponatremia	Generally avoid thiazide diuretic
Renovascular disease	Generally avoid ACE inhibitor, ARB, or renin inhibitor

ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker.

* A benefit from an aldosterone antagonist has been demonstrated in patients with NYHA class III-IV heart failure or decreased left ventricular ejection fraction after a myocardial infarction.

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AF, hyperthyroidism은 아니지만 baseline HR가 120회/분인 환자가 내원하였습니다. 혈압약을 복용한지는 3년 되었고 ARB 1 tablet을 복용 중이었습니다. 무조건 ARB가 first-line은 아니고 이러한 경우는 beta-blocker가 ARB보다 낫습니다. 혈압 강하와 HR 감소 목적입니다. Nebivolol 5 mg 복용으로 HR 70-80회/분 유지되어 변경한 약을 계속 복용하기로 하였습니다.

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Inappropriate sinus tachycardia — Treatment of symptomatic inappropriate sinus tachycardia is frequently challenging, often with suboptimal results. Prior to beginning treatment, it is important to exclude other etiologies of sinus tachycardia, notably postural orthostatic tachycardia syndrome (POTS), and continue withdrawing any medications that may be contributing to tachycardia (eg, stimulants). The pharmacologic management of inappropriate sinus tachycardia continues to evolve as new treatments are being developed. Once other etiologies of sinus tachycardia have been excluded, our approach to therapy is as follows:

㉮ For patients with symptomatic inappropriate sinus tachycardia, we suggest a trial of beta blockade as the initial medical therapy.

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㉯ For patients with persistently symptomatic inappropriate sinus tachycardia after a trial of beta blockers, we suggest using ivabradine (5 mg to 7.5 mg twice daily).

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㉰ Radiofrequency catheter ablation to modify the sinus node may be a treatment of last resort for patients with refractory symptoms. However, symptomatic recurrence after sinus node modification is frequent, and repeated procedures often result in pacemaker implantation.

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REF. UpToDate 2020.06.22