Nitrates for acute heart failure syndromes

There may not be difference in the rapidity of symptom relief between intravenous nitrate vasodilator therapy and alternative interventions in patients with acute heart failure syndromes.

The quality of evidence is downgraded by study limitations (unclear allocation concealment), and by imprecise results (few patients).

Summary

A Cochrane review included 4 studies with a total of 634 subjects; 74% of them were male. Two studies included only patients with acute heart failure syndromes (AHFS) following acute myocardial infarction (AMI); one study excluded patients with overt AMI; and one study included participants with AHFS with and without acute coronary syndromes. Two studies used intravenous isosorbide dinitrate and 2 studies intravenous nitroglycerin; one of the studies which employed nitroglycerin also employed N-acetylcysteine to potentiate the pharmacological effects of nitroglycerin. The studies compared nitrates with frusemide and morphine, frusemide alone, hydralazine, prenalterol, intravenous nesiritide and placebo.

Based on a single study, there was no significant difference in the rapidity of symptom relief (dyspnoea score, 0 to 3) between intravenous nitroglycerin/N-acetylcysteine and intravenous frusemide/morphine after 30 minutes (MD -0.30, 95% CI -0.65 to 0.05), 60 minutes (MD -0.20, 95% CI -0.65 to 0.25), three hours (MD 0.20, 95% CI -0.27 to 0.67) and 24 hours (MD 0.00, 95% CI -0.31 to 0.31). There is no evidence to support a difference in AHFS patients receiving intravenous nitrate vasodilator therapy or alternative interventions with regard to the following outcome measures: requirement for mechanical ventilation, systolic blood pressure (SBP) change after three hours and 24 hours, diastolic blood pressure (DBP) change after 30, 60 and 90 minutes, heart rate change at 30 minutes, 60 minutes, three hours and 24 hours, pulmonary artery occlusion pressure (PAOP) change after three hours and 18 hours, cardiac output (CO) change at 90 minutes and three hours and progression to myocardial infarction. There was a significantly higher incidence of adverse events after 3 hours with nitroglycerin compared with placebo (OR 2.29, 95% CI 1.26 to 4.16; 1 study). None of the included studies reported healthcare costs as an outcome measure. There were no data reported by any of the studies relating to the acceptability of the treatment to the patients (patient satisfaction scores).

Clinical comments

Date of latest search:

Ədəbiyyat

1. Wakai A, McCabe A, Kidney R et al. Nitrates for acute heart failure syndromes. Cochrane Database Syst Rev 2013;(8):CD005151.