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Low efficacy of intravenous TPA in acute cerebral infarction involving the large cerebral arteries.
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Arterial status after intravenous TPA therapy for ischaemic stroke: a need for further interventions.
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Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator.
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Late Endovascular Revascularization in Acute Ischemic Stroke Based on Clinical-Diffusion Mismatch
N. Janjua , A. El-Gengaihy , J. Pile-Spellman , A.I. Qureshi
American Journal of Neuroradiology May 2009, 30 (5) 1024-1027; DOI: 10.3174/ajnr.A1474
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Although beta blockers can produce life-threatening complications in patients with asthma, some patients taking beta 2 agonists can tolerate up to 100 mg daily of the beta 1 blocker metoprolol. 30 The use of beta blockers in patients with nonreversible chronic obstructive pulmonary disease (COPD) is less clear. While some COPD patients can tolerate beta blockers, others, particularly those who require beta 2 agonists, may have significant deterioration in pulmonary function. 31 Findings from a recent observational trial 9 suggest that beta blockers can be used safely in patients with COPD. In another study, 32 esmolol did not adversely affect pulmonary function in patients with nonreversible obstruction.

Although these results are encouraging, further study is needed in this area. In the meantime, it is wise to avoid the use of beta blockers in patients with asthma or COPD with a reversible component and in patients requiring bronchodilator therapy. In patients with mild, fixed obstruction, beta-blocker use may be a consideration, provided there is close monitoring of symptoms and pulmonary function tests.

Peripheral vascular disease has generally been considered a contraindication to the use of beta blockers. Worsening of the symptoms of peripheral vascular disease or intermittent claudication has been noted in small uncontrolled reports of beta-blocker use in patients with peripheral vascular disease. 33 , 34 Nonselective agents that produce beta 2 blockade have been associated with the greatest risk. Conversely, a meta-analysis of 11 randomized, controlled trials found that beta blockers did not adversely affect symptoms, walking distance or blood flow in the calf muscles of patients with mild to moderate peripheral arterial disease. 35

Therefore, a trial of beta-blocker therapy can be initiated in patients with mild to moderate peripheral vascular disease. Beta 1 selective agents should be used, and patients should be monitored closely for worsening of symptoms. Because patients with Raynaud's phenomenon or severe arterial vascular disease were excluded from the meta-analysis, beta blockers cannot be recommended for use in these patients.

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Dosage recommendations for beta blockers after acute myocardial infarction are summarized in Table 3 . Although many physicians are concerned about the potential for beta blockers to precipitate heart failure, reduce exercise tolerance or otherwise impair quality of life, these risks can be minimized by using cardio-selective agents, initiating therapy at a low dosage and slowly increasing the dosage based on the patient's tolerance of the agent. Many adverse effects, such as fatigue or even worsening of left ventricular function, may be transient and resolve with continued therapy.

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