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CLINICAL RESEARCH: HEART FAILURE

In-Hospital Mortality in Patients With Acute Decompensated Heart Failure Requiring Intravenous Vasoactive Medications

An Analysis From the Acute Decompensated Heart Failure National Registry (ADHERE)

William T. Abraham, MD, FACC^_*,_*, Kirkwood F. Adams, MD, FACC, Gregg C. Fonarow, MD, FACC, Maria Rosa Costanzo, MD, FACC, Robert L. Berkowitz, MD, FACC^||, Thierry H. LeJemtel, MD^¶, Mei L. Cheng, PhD^#, Janet Wynne, MS^# the ADHERE Scientific Advisory Committee and Investigators ADHERE Study Group

^_* Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles Medical Center, Los Angeles, California
Midwest Heart Specialists, Naperville, Illinois
^|| Heart Failure Program, Hackensack University Medical Center, Hackensack, New Jersey
^¶ Cardiology Division, Albert Einstein College of Medicine, Bronx, New York
^# Scios Inc., Fremont, California.

Manuscript received September 27, 2004; revised manuscript received March 3, 2005, accepted March 10, 2005.

^_* Reprint requests and correspondence: Dr. William T. Abraham, 473 West 12th Avenue, Suite 110P, Davis Heart and Lung Research Institute, Columbus, Ohio 43210-1252. (Email: abraham-1{at}medctr.osu.edu).

OBJECTIVES: We sought to compare the in-hospital mortality of patients with acute decompensated heart failure (ADHF) who were receiving parenteral treatment with one of four intravenous vasoactive medications.

BACKGROUND: There are limited data regarding the effects of the choice of intravenous vasoactive medication on in-hospital mortality in patients hospitalized with ADHF.

METHODS: This was a retrospective analysis of observational patient data from the Acute Decompensated Heart Failure National Registry (ADHERE), a multicenter registry designed to prospectively collect data on each episode of hospitalization for ADHF and its clinical outcomes. Data from the first 65,180 patient episodes (October 2001 to July 2003) were included in this analysis. Cases in which patients received nitroglycerin, nesiritide, milrinone, or dobutamine were identified and reviewed (n = 15,230). Risk factor and propensity score-adjusted odds ratios (ORs) for in-hospital mortality were calculated.

RESULTS: Patients who received intravenous nitroglycerin or nesiritide had lower in-hospital mortality than those treated with dobutamine or milrinone. The risk factor and propensity score-adjusted ORs for nitroglycerin were 0.69 (95% confidence interval [CI] 0.53 to 0.89, p 0.005) and 0.46 (94% CI 0.37 to 0.57, p 0.005) compared with milrinone and dobutamine, respectively. The corresponding values for nesiritide compared with milrinone and dobutamine were 0.59 (95% CI 0.48 to 0.73, p 0.005) and 0.47 (95% CI 0.39 to 0.56, p 0.005), respectively. The adjusted OR for nesiritide compared with nitroglycerin was 0.94 (95% CI 0.77 to 1.16, p = 0.58).

CONCLUSIONS: Therapy with either a natriuretic peptide or vasodilator was associated with significantly lower in-hospital mortality than positive inotropic therapy in patients hospitalized with ADHF. The risk of in-hospital mortality was similar for nesiritide and nitroglycerin.

Abbreviations and Acronyms   ADHERE = Acute Decompensated Heart Failure National Registry   ADHF = acute decompensated heart failure   BUN = blood urea nitrogen   CI = confidence interval   HF = heart failure   IV = intravenous   LVEF = left ventricular ejection fraction   OR = odds ratio

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