title: Effect of adding nitroglycerin to early diuretic therapy on the morbidity and mortality of patients with chronic kidney disease presenting with acute decompensated heart failure.
abstract: BACKGROUND
  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).
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors: 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. EA2168@Columbia.edu
authors: Emad F
authors: EF
authors: Aziz
authors: Marrick
authors: M
authors: Kukin
authors: Fahad
authors: F
authors: Javed
authors: Balaji
authors: B
authors: Pratap
authors: Manpreet Singh
authors: MS
authors: Sabharwal
authors: Deborah
authors: D
authors: Tormey
authors: Olivier
authors: O
authors: Frankenberger
authors: Eyal
authors: E
authors: Herzog
mesh_terms: D000368:Aged; D016009:Chi-Square Distribution; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital; D005260:Female; D005665:Furosemide / Q000627:therapeutic use*; D005919:Glomerular Filtration Rate; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D005996:Nitroglycerin / Q000627:therapeutic use*; D010359:Patient Readmission / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D012189:Retrospective Studies; D049994:Sodium Potassium Chloride Symporter Inhibitors / Q000627:therapeutic use*; D014665:Vasodilator Agents / Q000627:therapeutic use*
chemical_list: D049994:Sodium Potassium Chloride Symporter Inhibitors; D014665:Vasodilator Agents; D005665:Furosemide; D005996:Nitroglycerin