Aziz Emad F, Kukin Marrick, Javed Fahad, Pratap Balaji, Sabharwal Manpreet Singh, Tormey Deborah, Frankenberger Olivier, Herzog Eyal
Division of Cardiology, Advanced Cardiac Admission Program (ACAP), St. Luke's and Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY 10025, USA.
Hosp Pract (1995). 2011 Feb;39(1):126-32. doi: 10.3810/hp.2011.02.382.
Loop diuretics are considered first-line therapy for patients with acute decompensated heart failure (ADHF). Adding nitroglycerin (NTG) to diuretic therapy for alleviation of acute shortness of breath has been advocated in our institution. We evaluated the benefits of adding NTG to diuretics in the emergency department for patients with ADHF and chronic kidney disease (CKD).
430 consecutive patients with ADHF who were admitted with a chief complaint of dyspnea were included in this retrospective study. Patients were divided into 3 groups. Group A patients were treated with neither diuretics nor NTG; Group B patients were treated with diuretics only; and Group C patients were treated with both diuretics and NTG. Estimated glomerular filtration rate (GFR) was calculated according to the Cockcroft-Gault formula. Follow-up was 36 ± 9 (mean ± standard deviation [SD]) months. Primary endpoints were readmission rate at 30 days and mortality at 24 months.
430 patients were included in this study (42% men; age, 69 ± 14 [mean ± SD] years); mean New York Heart Association class was 2.4 ± 0.7 (mean ± SD) and mean ejection fraction was 28% ± 17% (mean ± SD). Group A included 257 (59%) patients, Group B had 127 (29%) patients, and Group C had 46 (11%) patients. Group C patients were older (mean age, 72 ± 13 years) with lower body mass index (26 ± 7 kg/m2), lower estimated GFR (55.8 ± 38 mL/min per 1.73 m2), higher B-type natriuretic peptide levels (1112 ± 876 pg/mL; P = nonsignificant [NS]), and higher systolic and diastolic blood pressures on admission (P = 0.001). The primary endpoint was assessed as a composite of all-cause mortality and ADHF readmission seen in 143 (56%) Group A patients, 68 (53%) Group B patients, and 22 (48%) Group C patients (P = NS). At 30 days there were 53 (12%) readmissions--26 in Group A, 20 in Group B, and 7 in Group C (P = NS). However, survival at 24 months was higher in Group C (87%) compared with Groups A (79%) and B (82%) (P = 0.002). Using the Cox proportional-hazards regression module, early administration of NTG and Lasix (95% confidence interval [CI], 1.06-1.62; P = 0.01) followed by CKD stage (95% CI, 1.00-1.35; P = 0.04) were the only predictors for survival.
There is a role for early administration of NTG in addition to diuretic therapy in patients admitted to the emergency department with ADHF, with resultant decreased length of stay and a trend toward a decrease in the composite endpoint of all-cause mortality and ADHF readmission. The mortality benefit at 2 years reported in our study is thought-provoking and raises a premise to be proven in randomized clinical trials.
袢利尿剂被认为是急性失代偿性心力衰竭（ADHF）患者的一线治疗药物。在我们机构，有人主张在利尿剂治疗中加用硝酸甘油（NTG）以缓解急性气短症状。我们评估了在急诊科对ADHF合并慢性肾脏病（CKD）患者在利尿剂基础上加用NTG的益处。
本回顾性研究纳入了430例以呼吸困难为主诉入院的连续ADHF患者。患者分为3组。A组患者既未接受利尿剂治疗也未接受NTG治疗；B组患者仅接受利尿剂治疗；C组患者接受利尿剂和NTG联合治疗。根据Cockcroft-Gault公式计算估算肾小球滤过率（GFR）。随访时间为36±9（均值±标准差[SD]）个月。主要终点为30天再入院率和24个月死亡率。
本研究纳入430例患者（42%为男性；年龄69±14[均值±SD]岁）；纽约心脏协会平均分级为2.4±0.7（均值±SD），平均射血分数为28%±17%（均值±SD）。A组包括257例（59%）患者，B组有127例（29%）患者，C组有46例（11%）患者。C组患者年龄较大（平均年龄72±13岁），体重指数较低（26±7kg/m²），估算GFR较低（55.8±38mL/min/1.73m²），入院时B型利钠肽水平较高（1112±876pg/mL；P=无显著差异[NS]），收缩压和舒张压较高（P=0.001）。主要终点评估为全因死亡率和ADHF再入院的综合情况，A组143例（56%）患者、B组68例（53%）患者和C组22例（48%）患者出现该情况（P=NS）。30天时共有53例（12%）再入院——A组26例，B组20例，C组7例（P=NS）。然而，C组24个月生存率（87%）高于A组（79%）和B组（82%）（P=0.002）。使用Cox比例风险回归模型，早期给予NTG和速尿（95%置信区间[CI]，1.06 - 1.62；P=0.01）以及CKD分期（95%CI，1.00 - 1.35；P=0.04）是生存的唯一预测因素。
对于因ADHF入住急诊科的患者，在利尿剂治疗基础上早期给予NTG具有一定作用，可使住院时间缩短，并使全因死亡率和ADHF再入院这一综合终点有下降趋势。我们研究中报告的2年死亡率获益发人深省，并提出了一个有待在随机临床试验中证实的前提。
