Nitrates for acute heart failure syndromes

Wakai, Abel; McCabe, Aileen; Kidney, Rachel; Brooks, Steven C.; Seupaul, Rawle A.; Diercks, Deborah B.; Salter, Nigel; Fermann, Gregory J.; Pospisil, Caroline

doi:10.1002/14651858.cd005151.pub2

Cited by 69 publications

(64 citation statements)

References 55 publications

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“…34 Conversely, it is important to mention Wakai et al, in a Cochrane review, could not contradict the current recommendation as their review could offer no evidence to alter the current standard use. 35 …”

Section: Challenges To Current Guidelinesmentioning

confidence: 99%

Nitrates as a Treatment of Acute Heart Failure

Alzahri

Rohra

Peacock

2016

Cardiac Failure Review

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Acute heart failure (AHF) presents symptoms primarily the result of pulmonary congestion due to elevated left ventricular (LV) filling pressures with or without reduced ejection fraction (EF). Common precipitating pathology includes coronary artery disease (CAD), hypertension and valvular heart diseases, in addition to other noncardiac conditions, such as diabetes, anaemia and kidney dysfunction. 1,2Additionally, AHF poses major medical and socioeconomic burdens.It represents the most common discharge diagnosis in patients over 65 years of age in the US, and an AHF patient that requires hospitalisation has a 90-day mortality approaching 10 %. 3,4 The cornerstone of AHF treatment is diuretics and vasodilators, such as nitrates. Due to a lack of randomised controlled trials, the use of nitrates for management of AHF is not universally adopted.While organic nitrates are among the oldest treatments for chronic stable angina, they are underutilised in AHF. Organic nitrates are available as sublingual tablets, capsules, sprays, patches, ointments or intravenous (IV) solutions, all of which are potent vasodilators.Because of the challenges in AHF research, a data imbalance between acute and chronic HF treatment exists as more studies have been performed in the latter. Thus, the current level of evidence for the use of nitrates in AHF is only rated as 1C, i.e., 'expert opinion'. 5,6 The purpose of this article is to review the clinical efficacy and safety data of nitrates in AHF. Applied to the patient with congestive HF, vasodilatation induces a substantial reduction in biventricular filling pressure. Moreover, it reduces systemic and pulmonary vascular resistance and systemic arterial blood pressure (BP), 11 all of which lead to modest increases in cardiac stroke volume and cardiac output. How Nitrate Works Mechanism of Action 12Overall, the two most commonly used IV NO sources used clinically in the setting of AHF is the organic nitrate donor nitroglycerin, and the inorganic nitrate source sodium nitroprusside (SNP). Nitroglycerin potently dilates large arteries (including coronary arteries) but has less effect on smaller arterioles, while SNP is a predominant arteriolar dilator. That makes SNP is effective in recompensating patients with AHF. 13 Other important clinical differences between organic and inorganic nitrates are summarised in Table 1. AbstractThe purpose of this article is to review the clinical efficacy and safety of nitrates in acute heart failure (AHF) by examining various trials on nitrates in AHF. Management of AHF can be challenging due to the lack of objective clinical evidence guiding optimal management.There have been many articles suggesting that, despite a benefit, nitrates are underused in clinical practice. Nitrates, when appropriately dosed, have a favourable effect on symptoms, blood pressure, intubation rates, mortality and other parameters.

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Section: Challenges To Current Guidelinesmentioning

confidence: 99%

Nitrates as a Treatment of Acute Heart Failure

Alzahri

Rohra

Peacock

2016

Cardiac Failure Review

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“…8 The most commonly used vasodilator is nitroglycerin, which is usually administered through the IV route but can be used sublingually in earlier phases. 9,10 A Cochrane Library review on the use of nitrates in AHF syndromes 11 found only 4 studies, which included a total of 634 patients: 2 were studies of patients who developed AHF after an acute myocardial infarction, another excluded patients with acute myocardial infarction, and the fourth included patients with and without acute coronary syndrome. The review concluded that the studies were of very poor quality and did not allow robust evidence to be obtained.…”

Section: Introductionmentioning

confidence: 99%

Influence of Intravenous Nitrate Treatment on Early Mortality Among Patients With Acute Heart Failure. NITRO-EAHFE Study

Herrero‐Puente

Jacob

Martín‐Sánchez

et al. 2015

Revista Española de Cardiología (English Edition)

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“…In this study, the authors reported that the high nitrate low furosemide group was associated with a lower requirement for mechanical ventilation, lower incidence of myocardial infarction (MI), and fewer adverse events compared to the high furosemide group and better in controlling severe pulmonary edema [15]. Despite these findings, a recent Cochrane meta-analysis has highlighted concern about trials examining nitrates in AHF and the paucity of evidence for their use [21]. Of the four trials they reviewed (the above trial by Cotter and colleagues was excluded because nitrates were used in both groups), they found no evidence to support the efficacy of nitrates in relieving dyspnoea, reducing blood pressure, reducing heart rate, or preventing MI postadmission [19,[22][23][24].…”

Section: Discussionmentioning

confidence: 99%

Underutilization of IV Nitrates in the Treatment of Acute Heart Failure

Mohan

Hawkey

Baig

et al. 2015

Cardiovascular Therapeutics

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SUMMARYAcute heart failure (AHF) is a growing public health concern with high inhospital mortality and costs. Clinical practice guidelines, underpinned by positive randomized controlled trials, recommend the early use of intravenous (IV) nitrates in the treatment of AHF. However, the "real-world" usage of IV nitrates has not been clearly defined. The objective of this study was to examine the use of IV nitrates in the treatment of AHF as recommended by clinical practice guidelines. A case-record analysis was conducted of all admissions with AHF at a large teaching hospital. Of the 81 AHF patients (mean age 77 AE 11, mean SBP 130 AE 27 mmHg) enrolled for this analysis, only 5 (6%) received IV nitrates at the time of AHF admission. Forty (49%, mean age 77 AE 11, mean SBP 131 AE 27 mmHg) of these 81 patients met the guideline criteria for suitability for IV nitrates and only 5 (12%) of these received them during this admission. Patients who received IV nitrates were more likely to have higher blood pressure and all had myocardial ischemia as a precipitant. Seventy-five (93%) of the total population received loop diuretics on admission. Overall, this study shows that loop diuretics remain the first-line therapy in AHF with little use of IV nitrates, despite recommendations from clinical practice guidelines.

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Nitrates for acute heart failure syndromes

Cited by 69 publications

References 55 publications

Nitrates as a Treatment of Acute Heart Failure

Nitrates as a Treatment of Acute Heart Failure

Influence of Intravenous Nitrate Treatment on Early Mortality Among Patients With Acute Heart Failure. NITRO-EAHFE Study

Underutilization of IV Nitrates in the Treatment of Acute Heart Failure

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