Nitrates for acute heart failure syndromes - PubMed (original) (raw)

Review

Nitrates for acute heart failure syndromes

Abel Wakai et al. Cochrane Database Syst Rev. 2013.

Abstract

Background: Current drug therapy for acute heart failure syndromes (AHFS) consists mainly of diuretics supplemented by vasodilators or inotropes. Nitrates have been used as vasodilators in AHFS for many years and have been shown to improve some aspects of AHFS in some small studies. The aim of this review was to determine the clinical efficacy and safety of nitrate vasodilators in AHFS.

Objectives: To quantify the effect of different nitrate preparations (isosorbide dinitrate and nitroglycerin) and the effect of route of administration of nitrates on clinical outcome, and to evaluate the safety and tolerability of nitrates in the management of AHFS.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (1950 to July week 2 2011) and EMBASE (1980 to week 28 2011). We searched the Current Controlled Trials MetaRegister of Clinical Trials (compiled by Current Science) (July 2011). We checked the reference lists of trials and contacted trial authors. We imposed no language restriction.

Selection criteria: Randomised controlled trials comparing nitrates (isosorbide dinitrate and nitroglycerin) with alternative interventions (frusemide and morphine, frusemide alone, hydralazine, prenalterol, intravenous nesiritide and placebo) in the management of AHFS in adults aged 18 and over.

Data collection and analysis: Two authors independently performed data extraction. Two authors performed trial quality assessment. We used mean difference (MD), odds ratio (OR) and 95% confidence intervals (CI) to measure effect sizes. Two authors independently assessed and rated the methodological quality of each trial using the Cochrane Collaboration tool for assessing risk of bias.

Main results: Four studies (634 participants) met the inclusion criteria. Two of the included studies included only patients with AHFS following acute myocardial infarction (AMI); one study excluded patients with overt AMI; and one study included participants with AHFS with and without acute coronary syndromes.Based on a single study, there was no significant difference in the rapidity of symptom relief between intravenous nitroglycerin/N-acetylcysteine and intravenous frusemide/morphine after 30 minutes (fixed-effect MD -0.30, 95% CI -0.65 to 0.05), 60 minutes (fixed-effect MD -0.20, 95% CI -0.65 to 0.25), three hours (fixed-effect MD 0.20, 95% CI -0.27 to 0.67) and 24 hours (fixed-effect MD 0.00, 95% CI -0.31 to 0.31). There is no evidence to support a difference in AHFS patients receiving intravenous nitrate vasodilator therapy or alternative interventions with regard to the following outcome measures: requirement for mechanical ventilation, systolic blood pressure (SBP) change after three hours and 24 hours, diastolic blood pressure (DBP) change after 30, 60 and 90 minutes, heart rate change at 30 minutes, 60 minutes, three hours and 24 hours, pulmonary artery occlusion pressure (PAOP) change after three hours and 18 hours, cardiac output (CO) change at 90 minutes and three hours and progression to myocardial infarction. There is a significantly higher incidence of adverse events after three hours with nitroglycerin compared with placebo (odds ratio 2.29, 95% CI 1.26 to 4.16) based on a single study. There was no consistent evidence to support a difference in AHFS patients receiving intravenous nitrate vasodilator therapy or alternative interventions with regard to the following secondary outcome measures: SBP change after 30 and 60 minutes, heart rate change after 90 minutes, and PAOP change after 90 minutes. None of the included studies reported healthcare costs as an outcome measure. There were no data reported by any of the studies relating to the acceptability of the treatment to the patients (patient satisfaction scores).Overall there was a paucity of relevant quality data in the included studies. Assessment of overall risk of bias in these studies was limited as three of the studies did not give sufficient detail to allow assessment of potential risk of bias.

Authors' conclusions: There appears to be no significant difference between nitrate vasodilator therapy and alternative interventions in the treatment of AHFS, with regard to symptom relief and haemodynamic variables. Nitrates may be associated with a lower incidence of adverse effects after three hours compared with placebo. However, there is a lack of data to draw any firm conclusions concerning the use of nitrates in AHFS because current evidence is based on few low-quality studies.

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Conflict of interest statement

None known.

Figures

1

1

Study flow diagram.

2

2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

3

3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

1.1

1.1. Analysis

Comparison 1: Changes in systolic blood pressure, Outcome 1: Change in SBP after 90 mins (nitrates vs frusemide)

2.1

2.1. Analysis

Comparison 2: Changes in diastolic blood pressure after 90 minutes, Outcome 1: Change in DBP (nitrates vs frusemide)

3.1

3.1. Analysis

Comparison 3: Changes in heart rate, Outcome 1: Change in heart rate at 90 minutes (nitrates vs frusemide)

4.1

4.1. Analysis

Comparison 4: Changes in cardiac output, Outcome 1: Change in cardiac index at 90 minutes (nitrates vs frusemide)

5.1

5.1. Analysis

Comparison 5: Changes in pulmonary artery occlusion pressure, Outcome 1: Change in pulmonary artery occlusion pressure at 90 minutes (nitrates vs frusemide)

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References

References to studies included in this review

Beltrame 1998 {published data only}
    1. Beltrame J, Zeitz C, Unger S, Brennan R, Moran J, Horowitz J. Nitrate therapy is an alternative to furosemide/morphine therapy in the management of acute cardiogenic pulmonary oedema. Journal of Cardiac Failure 1998;4(4):271-9. [PMID: ] - PubMed
Nelson 1983 {published data only}
    1. Nelson GIC, Silke B, Ahuja RC, Hussain M, Taylor SH. Haemodynamic advantages of isosorbide dinitrate over frusemide in acute heart failure following myocardial infarction. Lancet 1983;321:730-3. [PMID: ] - PubMed
Verma 1987 {published data only}
    1. Verma SP, Silke B, Hussain M, Nelson G, Reynolds GW, Richmond A, et al. First-line treatment of left ventricular failure complicating acute myocardial infarction: a randomised evaluation of immediate effects of diuretic, venodilator, arteriodilator, and positive inotropic drugs on left ventricular function. Journal of Cardiovascular Pharmacology 1987;10:38-46. [PMID: ] - PubMed
VMAC 2002 {published data only}
    1. Publication committee for the VMAC Investigators. Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure. JAMA 2002;287(12):1531-40. [PMID: ] - PubMed

References to studies excluded from this review

Cotter 1998 {published data only}
    1. Cotter G, Metzkor E, Kaluski E, Faigenberg Z. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet 1998;351:389-93. [PMID: 9482291] - PubMed
Elkayam 2004 {published data only}
    1. Elkayam U, Akhter MW, Singh H, Khan S, Usman A. Comparison of effects on left ventricular filling pressure of intravenous nesiritide and high-dose nitroglycerin in patients with decompensated heart failure. American Journal of Cardiology 2004;93:237-40. [PMID: ] - PubMed

Additional references

Adamson 2011
    1. Adamson PB, Zile MR, Cho YK, Bennett TD, Bourge RC, Aaron MF, et al. Hemodynamic factors associated with acute decompensated heart failure: part 2 - use in automated detection. Journal of Cardiac Failure 2011;17(5):366-73. [PMID: ] - PubMed
ADHERE 2003
    1. The ADHERE Registry. First Quarter 2003 National Benchmark Report. The ADHERE Registry 2003.
AHA 2001
    1. Heart and stroke statistical update. American Heart Association 2001.
Ambrosioni 1995
    1. Ambrosioni E, Borghi C, Magnani B (The Survival of Myocardial Infarction Long-Term Evaluation (SMILE) Study Investigators). The effect of the angiotensin-converting enzyme inhibitor zofenopril on mortality and morbidity after myocardial infarction. New England Journal of Medicine 1995;332:80-5. - PubMed
Berry 2001
    1. Berry C, Murdoch DR, McMurray JJ. Economics of chronic heart failure. European Journal of Heart Failure 2001;3:283-91. - PubMed
Bueno 1995
    1. Bueno H, Vidan MT, Almazan A, Lopez-Sendon JL, Delcan JL. Influence of sex on the short-term outcome of elderly patients with a first acute myocardial infarction. Circulation 1995;92:1133-40. - PubMed
Campana 1993
    1. Campana C, Gavazii A, Berzuini C, Larizza C, Marioni R, D'Armini A, et al. Predictors of prognosis in patients awaiting heart transplantation. Journal of Heart and Lung Transplantation 1993;12:756-65. - PubMed
Cleland 2001
    1. Cleland JGF, Khand A, Clark A. The heart failure epidemic: exactly how big is it? European Heart Journal 2001;22:623-6. - PubMed
Cleland 2003
    1. Cleland JG, Swedberg K, Follath F, Komajda M, Cohen-Solal A, Aguilar JC, et al. The EuroHeart Failure survey programme - a survey of the quality of care among patients with heart failure in Europe. Part 1: Patient characteristics and diagnosis. European Heart Journal 2003;24:442-63. - PubMed
Cotter 2000
    1. Cotter G, Kaluski E, Blatt A, Milovanov O, Moshkovitz Y, Zaidenstein R et al. L-NMMA (a nitric oxide synthase inhibitor) is effective in the treatment of cardiogenic shock. Circulation 2000;101:1358-61. - PubMed
Cotter 2003
    1. Cotter G, Moshkovitz Y, Kaluski E, Milo O, Nobikov Y, Schneeweiss A, et al. The role of cardiac power and systemic vascular resistance in the pathophysiology and diagnosis of patients with acute congestive heart failure. European Journal of Heart Failure 2003;5:443-51. - PubMed
Cowie 1997
    1. Cowie MR, Mosterd A, Wood DA, Deckers JW, Poole-Wilson PA, Suresh V, et al. The epidemiology of heart failure. European Heart Journal 1997;18:208-25. - PubMed
Crane 2002
    1. Crane SD. Epidemiology, treatment and outcome of acidotic, acute, cardiogenic pulmonary oedema presenting to an emergency department. European Journal of Emergency Medicine 2002;9:320-4. - PubMed
Deeks 2011
    1. Deeks JJ, Higgins JPT, Altman DG. Chapter 9: Analysing data and undertaking meta-analyses . In: Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011].. The Cochrane Collaboration, 2011.
DiDomenico 2004
    1. DiDomenico RJ, Park HY, Southworth MR, Eyrich HM, Lewis RK, Finley JM et al. Guidelines for acute decompensated heart failure treatment. Annals of Pharmacotherapy 2004;38:646-60. - PubMed
DiGuili 2001
    1. DiGuili F, Anand I. Current issues in heart failure. Acute Heart Failure 2001.
Doughty 1995
    1. Doughty R, Yee T, Sharpe N, MacMahon S. Hospital admissions and deaths due to congestive heart failure in New Zealand, 1981-1991. New Zealand Medical Journal 1995;108:473-5. - PubMed
Eriksson 1991
    1. Eriksson H, Wilhelmsen L, Caidahl K, Svardsudd K. Epidemiology and prognosis of heart failure. Zeitschrift fur Kardiologie 1991;80:1-6. - PubMed
Fonarow 2001
    1. Fonarow GC. The treatment targets in acute decompensated heart failure. Reviews in Cardiovascular Medicine 2001;2:S7-S12. - PubMed
Fonarow 2002
    1. Fonarow GC. Pharmacologic therapies for acutely decompensated heart failure. Reviews in Cardiovascular Medicine 2002;3:S18-S27. - PubMed
Fonarow 2003
    1. Fonarow GC (ADHERE Scientific Advisory Committee). The Acute Decompensated Heart Failure National Registry (ADHERE): opportunities to improve care of patients hospitalized with acute decompensated heart failure. Reviews in Cardiovascular Medicine 2003;4:S21-S30. - PubMed
Fonarow 2008
    1. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF. Archives of Internal Medicine 2008;168:847-54. [PMID: ] - PubMed
Ghali 1990
    1. Ghali JK, Cooper R, Ford E. Trends in hospitalisation rates for heart failure in the United States 1973-1986: evidence for screening population prevalence. Archives of Internal Medicine 1992;150:769-73. - PubMed
Gheorghiade 2005
    1. Gheorghiade M, Zannad F, Sopko G, Klein L, Piña IL, Konstam MA, et al. Acute heart failure syndromes: current state and framework for future research. Circulation 2005;20(112(25)):3958-68. - PubMed
GISSI‐3 1994
    1. GISSI-3. Effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction. Lancet 1994;343:1115-23. - PubMed
Glasziou 2001
    1. Glasziou P, Irwig L, Bain C, Colditz G. Systematic Reviews in Health Care: a Practical Guide. Cambridge: Cambridge University Press, 2001.
Hellermann 2002
    1. Hellermann JP, Jacobsen SJ, Gersh BJ, Rodeheffer RJ, Reeder GS, Roger VL. Heart failure after myocardial infarction: a review. American Journal of Medicine 2002;113:324-30. - PubMed
Higgins 2003
    1. Higgins JPT, Thompson SG, Deeks JD, Altman G. Measuring inconsistency in meta-analysis. BMJ 2003;327:557-60. [MEDLINE: ] - PMC - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Hochman 1999
    1. Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. New England Journal of Medicine 1999;341:625-34. - PubMed
Hunt 2001
    1. Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult. Journal of the American College of Cardiology 2001;38:2101-13. - PubMed
Imhof 1980
    1. Imhof PR, Ott B, Frankhauser P, Chu LC, Hodler J. Difference in nitroglycerin dose response in the venous and arterial beds. European Journal of Clinical Pharmacology 1980;18:455-60. - PubMed
ISIS‐4 1995
    1. Anonymous. ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58 050 patients with suspected acute myocardial infarction. ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group. Lancet 1995;345:669-85. - PubMed
Kaluski 2003
    1. Kaluski E, Kobrin I, Zimlichman R, Marmov A, Krakov O, Milo O, et al. RITZ-5: Randomized intravenous tezosentan (an endothelin-A/B antagonist) for the treatment of pulmonary edema. A prospective, multicenter, double-blind, placebo-controlled study. Journal of the American College of Cardiology 2003;41:204-10. - PubMed
Khan 1996
    1. Khan KS, Daya S, Jadad A. The importance of quality of primary studies in producing unbiased systematic reviews. Archives of Internal Medicine 1996;156:661-6. [PMID: ] - PubMed
Khand 1999
    1. Khand A, Gemmel I, Clark AL, Cleland JGF. Is the prognosis of heart failure improving? European Journal of Heart Failure 1999;1:229-41. - PubMed
Lau 1998
    1. Lau J, Ioannidis JPA, Schmid CH. Quantitative synthesis in systematic reviews. In: Mulrow C, Cook D, editors(s). Systematic Reviews: Synthesis of Best Evidence for Health Care Decisions. 1st edition. Philadelphia: American College of Physicians, 1998:91-101.
Lefebvre 2011
    1. Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. Using the Cochrane sensitivity-maximising RCT filter. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Lucas 2000
    1. Lucas C, Johnson W, Hamilton MA, Fonarow GC, Woo MA, Flavell CM, et al. Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure. American Heart Journal 2000;140:840-7. - PubMed
McMurray 2012
    1. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European Journal of Heart Failure 2012;14(8):803-69. [PMID: ] - PubMed
Mebazaa 2010
    1. Mebazaa A, Pang PS, Tavares M, Collins SP, Storrow AB, Laribi S, et al. The impact of early standard therapy on dyspnoea in patients with acute heart failure: the URGENT- dyspnoea study. European Heart Journal 2010;31(7):832-41. [PMID: ] - PubMed
Nohria 2002
    1. Nohria A, Lewis E, Stevenson LW. Medical management of advanced heart failure. JAMA 2002;287:628-40. - PubMed
Pang 2008
    1. Pang PS, Cleland JG, Teerlink JR, Collins SP, Lindsell CJ, Sopko G, et al. A proposal to standardize dyspnoea measurement in clinical trials of acute heart failure syndromes: the need for a uniform approach. European Heart Journal 2008;29(6):816-24. [PMID: ] - PubMed
Pang 2010
    1. Pang PS, Komajda M, Gheorghiade M. The current and future management of acute heart failure syndromes. European Heart Journal 2010;31(7):784-93. [PMID: ] - PubMed
Peacock 2004
    1. Peacock WF, Emerman CL, Young J. Nesiritide in congestive heart failure associated with acute coronary syndromes: a pilot study of safety and efficacy. Journal of Cardiac Failure 2004;10:120-5. - PubMed
Reitsma 1996
    1. Reitsma JB, Mosterd A, Craen AJ, Koster RW, Capelle FJ, Grobbee DE, et al. Increase in hospital admission rates for heart failure in the Netherlands, 1980-1993. Heart 1996;76:388-92. - PMC - PubMed
RevMan 5.2 [Computer program]
    1. The Nordic Centre, The Cochrane Collaboration Review Manager (RevMan). Version 5.2. Copenhagen: The Nordic Centre, The Cochrane Collaboration, 2012.
Rodriguez 1997
    1. Rodriguez-Artalejo F, Guallar-Castillon P, Banegas Banegas JR, Rey Calero J. Trends in hospitalization and mortality for heart failure in Spain, 1980-1993. European Heart Journal 1997;18:388-92. - PubMed
Roger 2011
    1. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics--2011 update: a report from the American Heart Association.. Circulation 2011;1(123(4)):e18-e209. - PMC - PubMed
Schappert 2008
    1. Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. National Health Statistics Reports 2008;6(8):1-29. - PubMed
Sharon 2000
    1. Sharon A, Shpirer I, Kalunski E, Moshkovitz Y, Milovanov O, Polak R, et al. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. Journal of the American College of Cardiology 2000;36:832-7. - PubMed
Spencer 1999
    1. Spencer FA, Meyer TE, Goldberg RJ, Yarzebski J, Hatton M, Lessard D, et al. Twenty year trends (1975-1995) in the incidence, in-hospital and long-term death rates associated with heart failure complicating acute myocardial infarction: a community-wide perspective. Journal of the American College of Cardiology 1999;34:1378-87. - PubMed
Spencer 2002
    1. Spencer FA, Meyer TE, Gore JM, Goldberg RJ. Heterogeneity in the management and outcomes of patients with acute myocardial infarction complicated by heart failure: the National Registry of Myocardial Infarction. Circulation 2002;105:2605-10. [MEDLINE: ] - PubMed
Steg 2004
    1. Steg PG, Dabbous OH, Feldman LJ, Cohen-Solal A, Aumont MC, Lopez-Sendon J, et al. Determinants and prognostic impact of heart failure complicating acute coronary syndromes: observations from the Global Registry of Acute Coronary Events (GRACE). Circulation 2004;109:494-9. - PubMed
Stevenson 1999
    1. Stevenson LW. Tailored therapy to hemodynamic goals for advanced heart failure. European Journal of Heart Failure 1999;1:251-7. - PubMed
Stewart 2001
    1. Stewart S, MacIntyre K, Hole DJ. More 'malignant' than cancer? 5-year survival following a first admission with heart failure. European Journal of Heart Failure 2001;3:315-22. - PubMed
Stewart 2002
    1. Stewart S, Jenkins A, Buchan A, McGuire A, Capewell S, McMurray JJ. The current cost of heart failure to the National Health Service in the UK. European Journal of Heart Failure 2001;3:361-71. - PubMed
Stewart 2003
    1. Stewart S, MacIntyre K, Capewell S, McMurray JJV. Heart failure and the aging population: an increasing burden in the 21st century? Heart 2003;89(1):49-53. - PMC - PubMed
Weintraub 2010
    1. Weintraub NL, Collins SP, Pang PS, Levy PD, Anderson AS, Arslanian-Engoren C, et al. Acute heart failure syndromes: emergency department presentation, treatment and disposition: current approaches and future aims: a scientific statement from the American Heart Association. Circulation 2010;122(19):1975-96. - PubMed
Whellan 2013
    1. Whellan DJ, Sarkar S, Koehler J, Small RS, Boyle A, Warman EN, et al. Development of a method to risk stratify patients with heart failure for 30-day readmission using implantable device diagnostics. American Journal of Cardiology 2013;111(1):79-84. [PMID: ] - PubMed
Wu 2002
    1. Wu AH, Parsons L, Every NR, Bates ER. Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2). Journal of the American College of Cardiology 2002;40:1389-94. - PubMed
Zile 2011
    1. Zile MR, Adamson PB, Cho YK, Bennett TD, Bourge RC, Aaron MF, et al. Hemodynamic factors associated with acute decompensated heart failure: part 1 - insights into pathophysiology. Journal of Cardiac Failure 2011;17(4):282-91. [PMID: ] - PubMed

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