title: Impact of Nitrate Use on Survival in Acute Heart Failure: A Propensity-Matched Analysis.
abstract: BACKGROUND
  There is limited evidence that the use of nitrates in acute decompensated heart failure early after presentation to a hospital can improve clinical outcomes. We aimed to determine whether early nitrate exposure is associated with improved survival in a large retrospective cohort study.
  
  
  RESULTS
  We examined 11 078 acute decompensated heart failure patients who presented to emergency departments in Ontario, Canada, between 2004 and 2007, in the Enhanced Feedback For Effective Cardiac Treatment and the Emergency Heart failure Mortality Risk Grade studies. In propensity-matched analyses, we examined the effect of nitrate administration in the acute emergency department setting for its impact on death at 7, 30, and 365 days. In propensity-matched analyses, we found no difference in survival between those who received nitrates in the emergency department and the non-nitrate comparator group. Hazard ratios for mortality were 0.76 (95% CI; 0.51, 1.12) over 7 days, 0.97 (95% CI; 0.77, 1.21) over 30 days, and 0.91 (95% CI; 0.82, 1.02) over 1 year of follow-up. There was no significant difference in survival or hospital length of stay between nitrate and non-nitrate controls in extended follow-up. There was also no significant effect of nitrates in subgroups stratified by presence of chest pain, troponin elevation, chronic nitrate use, and known coronary artery disease.
  
  
  CONCLUSIONS
  In acute decompensated heart failure, use of nitrates acutely in the emergency department setting was not associated with improvement in short-term or near-term survival. Our study does not support generalized use of nitrates when the primary goal of therapy is to reduce mortality.
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada University of Toronto, Canada.
authors.forename: Edwin C
authors.initials: EC
authors.lastname: Ho
authors.affiliation: Division of Cardiology, Mt. Sinai Hospital, Toronto, Ontario, Canada University of Toronto, Canada.
authors.forename: John D
authors.initials: JD
authors.lastname: Parker
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada University of Toronto, Canada.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Austin
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada University of Toronto, Canada.
authors.forename: Jack V
authors.initials: JV
authors.lastname: Tu
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Xuesong
authors.initials: X
authors.lastname: Wang
authors.affiliation: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada University of Toronto, Canada dlee@ices.on.ca.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Lee
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D016507:Cardiology Service, Hospital; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D004636:Emergency Service, Hospital; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D009566:Nitrates / Q000627:therapeutic use*; D009864:Ontario; D057216:Propensity Score; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
chemical_list: D002317:Cardiovascular Agents; D009566:Nitrates
keywords: angina; chronic ischemic heart disease; coronary artery disease; health services; heart failure; mortality/survival; myocardial infarction; quality and outcomes; statements and guidelines