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Evidence summaries

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. Level of evidence: "C"

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

Summary

A Cochrane review [Abstract] 1 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 furosemide and morphine, furosemide 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 furosemide/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), 3 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 3 hours and 24 hours, diastolic blood pressure (DBP) change after 30, 60 and 90 minutes, heart rate change at 30 minutes, 60 minutes, 3 hours and 24 hours, pulmonary artery occlusion pressure (PAOP) change after 3 hours and 18 hours, cardiac output (CO) change at 90 minutes and 3 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

According to the European Society of Cardiology (ESC) guideline 2 i.v. vasodilators should be considered for symptomatic relief in acute heart failure (AHF) with SBP >90 mmHg and without symptomatic hypotension with frequent monitoring of symptoms and blood pressure, and in patients with hypertensive AHF, i.v. vasodilators should be considered as initial therapy to improve symptoms and reduce congestion.

Note

Date of latest search:

    References

    • Wakai A, McCabe A, Kidney R et al. Nitrates for acute heart failure syndromes. Cochrane Database Syst Rev 2013;(8):CD005151. [PubMed]
    • Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37(27):2129-2200. [PubMed]

Primary/Secondary Keywords