Evaluation of the effect of intravenous nitroglycerine on short-term survival of patients with acute heart failure according to congestion and perfusion status at emergency department arrival.
Por:
Miró Ò, Espinosa B, Gil V, Jacob J, Alquézar-Arbé A, Masip J, Llauger L, Tost J, Andueza JA, Garrido JM, Mojarro EM, Urbano CA, Núñez J, Chioncel O, Mullens W, Cotter G and Llorens P
Publicada:
1 dic 2022
Ahead of Print:
20 jul 2022
Resumen:
We investigated if the phenotypic classification of acute heart failure (AHF) based on the number of signs/symptoms of congestion and hypoperfusion at emergency department (ED) arrival identifies subgroups in which intravenous (IV) nitroglycerine (NTG) use improves short-term survival. We included consecutive AHF patients diagnosed in 45 Spanish EDs, who were grouped according to phenotype severity. The main outcome was 30-day all-cause death. Propensity scores (PS) for NTG use were generated using variables associated with death. Analysis of interaction was performed in subgroups of patients based on congestion, hypoperfusion, age, sex, coronary artery disease (CAD), left ventricular ejection fraction (LVEF) and SBP. We analyzed 16 437 AHF patients (median = 83 years; women = 56%); 1882 received NTG (11.4%). In the whole cohort, the cumulative 30-day mortality in patients receiving NTG was higher (11.5% vs. 9.6%; unadjusted HR, 1.19; 95% CI, 1.04-1.36), but not in the PS-matched cohorts (1698 pairs of patients; 11.5% vs. 10.5%; HR, 1.10; 95% CI, 0.90-1.35). Mortality was increased in NTG-treated patients with mild congestion (HR, 2.09; 95% CI, 1.19-3.67), especially in those without hypoperfusion (HR, 2.51; 95% CI, 1.24-5.10). Interaction analysis of the PS-matched cohorts confirmed detrimental effects of NTG use in less congested patients, whereas beneficial effects were only observed in patients with decreased LVEF (<50% subgroup: HR, 0.59; 95% CI, 0.37-0.92; =50% subgroup: HR, 1.30; 95% CI, 0.66-2.56; P = 0.002). Phenotypical classification of AHF based on congestion/hypoperfusion at ED arrival does not identify subgroups of patients in whom IV-NTG would decrease mortality, although it could potentially be beneficial in those with LVEF of less than 50%. This hypothesis will have to be confirmed in the future. Conversely, our results suggest that IV-NTG may be harmful in patients with only mild clinical congestion.
Filiaciones:
Miró Ò:
Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona
:
Emergency, Short Stay and Hospitalization at Home Departments, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante
Gil V:
Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona
Jacob J:
Emergency Department, Hospital Universitari de Bellvitge, l'Hospitalet de Llobregat
Alquézar-Arbé A:
Emergency Department, Hospital de la Santa Creu i Sant Pau
Masip J:
Research Direction, Consorci Sanitari Integral
Llauger L:
Emergency Department, Hospital de Vic
Tost J:
Emergency Department, Consorci Sanitari de Terrassa, Barcelona
Andueza JA:
Emergency Department, Hospital General Universitario Gregorio Marañón, Madrid
Garrido JM:
Emergency Department, Hospital Virgen Macarena, Sevilla
Mojarro EM:
Emergency Department, Hospital Santa Tecla, Tarragona
Urbano CA:
Emergency Department, Hospital Costa del Sol, Marbella
Núñez J:
Cardiology Department, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA, Valencia, Spain
Chioncel O:
Emergency Institute for Cardiovascular Diseases, Prof. C.C. Iliescu, University of Medicine and Pharmacology Carol Davila, Bucarest, Romania
Mullens W:
Cardiology Department, Ziekenhuis Oost-Limburg, Genk, Hasselt University, Diepenbeek, Belgium and
Cotter G:
Momentum Research Inc, Chapel Hill, North Carolina, USA
:
Emergency, Short Stay and Hospitalization at Home Departments, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante
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