LETTER TO THE EDITOR
Cerebroprotection mediated by angiotensin II
Jalal K. Ghali, MD
Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71103
(Email: jghali{at}lsuhsc.edu).
I read with great interest the provocative study by Fournier et al. (1) on cerebroprotection mediated by angiotensin II. The investigators state that beta-blockers are remarkably ineffective in reducing the risk of stroke; however, they cite three studies all performed with one beta-blocker, atenolol, which has never been proven to reduce sudden death.
In general, the results of multiple studies with one drug cannot be interpreted as representing the class of that drug. In the case of beta-blockers in particular, publication of the Beta-blocker Evaluation of Survival Trial (BEST) (2), which failed to replicate the mortality reduction demonstrated by bisoprolol, metoprolol extended release, and carvedilol in systolic heart failure, clearly established the fallacy of assuming a class effect for the benefit of beta-blockers for that particular indication. Furthermore, in the recently published Carvedilol Or Metoprolol European Trial (COMET) (3), the stroke rate was reduced significantly (67%) with carvedilol compared with the short-acting metoprolol tartrate (4). Thus, the investigators need to limit their conclusion of the ineffectiveness of beta-blockers to atenolol and avoid invoking beta-blockers as a class in this argument.
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References
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1. Fournier A, Messerli FH, Achard JM, Fernandez L. Cerebroprotection mediated by angiotensin II: a hypothesis supported by recent randomized clinical trials J Am Coll Cardiol 2004;43:1343-1347.[Abstract/Free Full Text]
2. The Beta-blocker Evaluation of Survival Trial investigators A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure N Engl J Med 2001;344:1659-1667.[Abstract/Free Full Text]
3. Poole-Wilson PA, Swedberg K, Cleland JG, et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the carvedilol or metoprolol European Trial (COMET): randomised controlled trial Lancet 2003;362:7-13.[CrossRef][Medline]
4. Remme WJ, Cleland JG, Lenarda AD, et al., for the COMET Investigators. Carvedilol better protects against vascular events than metoprolol in heart failure: results from COMET (abstr). J Am Coll Cardiol 2004;43 Suppl A:205A..
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