Hemodynamics, diuretics, and nesiritide: a retrospective VMAC analysis.
OBJECTIVE
Hypotension has been proposed as the cause of nesiritide-associated increases in serum creatinine (SCr); however, this hypothesis has not been tested.


METHODS
This retrospective evaluation of patients who had a pulmonary artery catheter and received nesiritide in the Vasodilation in the Management of Acute Congestive Heart Failure (VMAC) trial assessed hypotension, SCr elevation, concomitant therapy, and mortality. Patients were categorized by baseline pulmonary capillary wedge pressure (PCWP) and analyzed both for overall population and by diuretic dose.


RESULTS
Compared with patients with PCWP > 23 mm Hg (n = 105), patients with PCWP < or = 23 mm Hg (n = 49) had more hypotension within 24 hours of initiating nesiritide (16% vs 7%), but neither more SCr elevation by nominal day 30 (29% vs 28%) nor higher mortality (30 days: 8.2% vs 7.7%; 6 months: 29.0% vs 29.3%). The risk of hypotension was directly related to high dose diuretics (25% vs 6%; relative risk [RR]: 4.2; 95% confidence interval [CI]: 1.10-15.82) and was not significantly increased in patients without this concomitant treatment (10% vs 7%; RR: 1.4; 95% CI: 0.34-5.93). Additionally, high dose diuretics significantly increased the risk of SCr elevation (RR: 2.6; 95% CI: 1.03-6.64) and 6 month mortality (hazard ratio: 3.6; 95% CI: 1.19-10.63) in patients with PCWP < or = 23 mm Hg.


CONCLUSIONS
Hypotension is not the primary etiology for nesiritide-associated increases in SCr. High dose diuretics increase the risk of adverse outcomes in patients with PCWP < or = 23 mm Hg and should be reserved for patients in whom PCWPs are known to be markedly elevated.
Young
James B
JB
Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA. youngj@ccf.org
Cheng
Mei
M
Mills
Roger M
RM
D000208:Acute Disease; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002407:Catheterization, Swan-Ganz; D003404:Creatinine / Q000097:blood; D004232:Diuretics / Q000009:adverse effects*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D006333:Heart Failure / Q000097:blood / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D007022:Hypotension / Q000097:blood / Q000139:chemically induced* / Q000401:mortality / Q000503:physiopathology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D020097:Natriuretic Peptide, Brain / Q000009:adverse effects*; D018579:Patient Selection; D011446:Prospective Studies; D011669:Pulmonary Wedge Pressure / Q000187:drug effects; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome; D015854:Up-Regulation; D014665:Vasodilator Agents / Q000009:adverse effects*
D015415:Biomarkers; D004232:Diuretics; D014665:Vasodilator Agents; D020097:Natriuretic Peptide, Brain; D003404:Creatinine