Early intravenous nitroglycerin use in prehospital setting and in the emergency department to treat patients with acute heart failure: Insights from the EAHFE Spanish registry

Miró, Òscar; Llorens, Pere; Freund, Yonathan; Davison, Beth A.; Takagi, Koji; Herrero‐Puente, Pablo; Jacob, Javier; Martín‐Sánchez, Francisco Javier; Gil, Víctor; Rosselló, Xavier; Alquézar‐Arbé, Aitor; Jiménez-Fàbrega, Francesc Xavier; Masip, Josep; Mebazaa, Alexandre; Cotter, Gad

doi:10.1016/j.ijcard.2021.09.031

Cited by 6 publications

(7 citation statements)

References 22 publications

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“…This study supports the favorable safety profile of prehospital highdose intravenous NTG use for treating AHFS with APE. The frequency of hypotension (1.3%) is similar to values documented in prior prehospital 21,22 and hospital- 10,11,23,24 based studies. Furthermore, this hypotension was transient, with no documented associated arrhythmia or altered mentation.…”

Section: Discussionsupporting

confidence: 80%

Safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema: A 4‐year review

Patrick,

Fornage,

Ward

et al. 2023

JACEP Open

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BackgroundIntravenous nitrates are a primary therapy for hypertensive congestive heart failure (CHF) with acute pulmonary edema (APE) in the hospital setting. Historically, sublingual nitrates are the mainstay of emergency medical services (EMS) pharmacologic therapy for these patients. We aimed to evaluate the safety of prehospital bolus dose intravenous nitroglycerin in patients with APE.MethodsThis is a retrospective evaluation of EMS data between March 15, 2018, and March 15, 2022, where CHF with APE was suspected and bolus‐dose intravenous nitroglycerin was administered. Protocol inclusion criteria were hypertension (systolic blood pressure [SBP] >160 mmHg) and acute respiratory distress, with a presumption of decompensated CHF with APE. These patients received 1 mg intravenous nitroglycerin, with the option to repeat once for ongoing distress if the SBP remained >160 mmHg. The primary outcomes were adverse events, defined as hypotension (SBP <90 mmHg), syncope, vomiting, or dysrhythmia.ResultsThe final analysis included 235 patients. In patients receiving intravenous bolus nitroglycerin, the median (interquartile range [IQR]) initial and final EMS SBP values decreased from 198 mmHg (180–218) to 168 (148–187), respectively. The median (IQR) pulse decreased from 108 (92–125) to 103 (86–119), and the median oxygen saturation increased from 89% (82–95) to 98% (96–99). Three episodes (1.3%) of asymptomatic hypotension occurred, and none required intervention.ConclusionThis study supports a favorable safety profile for prehospital bolus‐dose intravenous nitroglycerin for decompensated CHF with APE. Blood pressure, heart rate, and oxygen saturation improvements are also demonstrated. Further, prospective studies are needed to confirm these findings.

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Section: Discussionsupporting

confidence: 80%

Safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema: A 4‐year review

Patrick,

Fornage,

Ward

et al. 2023

JACEP Open

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“…Our subgroups analyses extensively failed in detecting any clinical setting with a more favourable setting for IV-NTG use in patients with AHF. Despite many authors have suggested that prompt initiation of IV-NTG in patients with severe pulmonary congestion (presenting in the form of acute pulmonary oedema) could be beneficial especially if it is quickly provided in the prehospital arena [8,[23][24][25], our subgroup analysis considering signs/symptoms of congestion separately according to whether they correspond to pulmonary or systemic congestion did not support this hypothesis, at least with respect to an improvement in patient survival. Similarly, age, sex, CAD as comorbidity and SBP did not have a different impact on the effects of NTG on patient survival.…”

Section: Discussioncontrasting

confidence: 76%

“…A later report that analyzed the impact of NTG administration in the ED to patients with AHF also did not observe any association with short-term survival [6], and the GALACTIC trial found no benefit in the administration of nitrates during the first few days of admission for AHF [7]. Conversely, a recent study showed that early prehospital IV-NTG administration was associated with lower mortality and postdischarge events (as proposed in the seminal study 40 years ago) and that this association was not observed when IV-NTG was started in the ED [8].…”

Section: Introductionmentioning

confidence: 99%

Evaluation of the effect of intravenous nitroglycerine on short-term survival of patients with acute heart failure according to congestion and perfusion status at emergency department arrival

Miró

Espinosa²,

Gil

et al. 2022

European Journal of Emergency Medicine

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Objectives: We investigated if the phenotypic classification of acute heart failure (AHF) based on the number of signs/ symptoms of congestion and hypoperfusion at emergency department (ED) arrival identifies subgroups in which intravenous (IV) nitroglycerine (NTG) use improves shortterm survival.Methods: We included consecutive AHF patients diagnosed in 45 Spanish EDs, who were grouped according to phenotype severity. The main outcome was 30-day all-cause death. Propensity scores (PS) for NTG use were generated using variables associated with death. Analysis of interaction was performed in subgroups of patients based on congestion, hypoperfusion, age, sex, coronary artery disease (CAD), left ventricular ejection fraction (LVEF) and SBP.Results: We analyzed 16 437 AHF patients (median = 83 years; women = 56%); 1882 received NTG (11.4%). In the whole cohort, the cumulative 30-day mortality in patients receiving NTG was higher (11.5% vs. 9.6%; unadjusted HR, 1.19; 95% CI, 1.04-1.36), but not in the PS-matched cohorts (1698 pairs of patients; 11.5% vs. 10.5%; HR, 1.10; 95% CI, 0.90-1.35). Mortality was increased in NTG-treated patients with mild congestion (HR, 2.09; 95% CI, 1.19-3.67), especially in those without hypoperfusion (HR, 2.51; 95% CI, 1.24-5.10). Interaction analysis of the PS-matched cohorts confirmed detrimental effects of NTG use in less congested patients, whereas beneficial effects were only observed in patients with decreased LVEF (<50% subgroup: HR, 0.59; 95% CI, 0.37-0.92; ≥50% subgroup: HR, 1.30; 95% CI, 0.66-2.56; P = 0.002). Conclusion: Phenotypical classification of AHF based on congestion/ hypoperfusion at ED arrival does not identify subgroups of patients in whom IV-NTG would decrease mortality, although it could potentially be beneficial in those with LVEF of less than 50%. This hypothesis will have to be confirmed in the future. Conversely, our results suggest that IV-NTG may be harmful in patients with only mild clinical congestion.

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“…This potentially has significant impact on patient outcomes as earlier initiation of HF therapies is associated with lower mortality and hospital readmission rates. 4,23 Our study differs from prior studies evaluating LUS in the prehospital setting as the majority have focused on diagnosis and have not evaluated impact on treatment. Zanatta et al 13 evaluated management changes comparing one ambulance with LUS and one without and found no significant differences in treatment between the two.…”

Section: Discussionmentioning

confidence: 97%

Prehospital lung ultrasound in acute heart failure: Impact on diagnosis and treatment

Russell,

Supples,

Tamhankar

et al. 2023

Academic Emergency Medicine

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ObjectivePatients with acute heart failure (AHF) are commonly misdiagnosed and undertreated in the prehospital setting. These delays in diagnosis and treatment have a direct negative impact on patient outcomes. The goal of this study was to determine the diagnostic accuracy of paramedics with and without the use of lung ultrasound (LUS) for the diagnosis of AHF in patients with dyspnea in the prehospital setting. Secondarily, we assessed LUS impact on rate of and time to initiation of HF therapies.MethodsThis was a prospective interventional study on a consecutive sample of patients transported to the hospital by one emergency medical services agency. Adult patients (>18) with a chief complaint of dyspnea were included. LUS was performed by trained paramedics and was defined as positive for AHF if both anterior‐superior lung zones had greater than or equal to 3 B‐lines or bilateral B‐lines were visualized on a 4‐view protocol. Paramedic diagnosis was compared to hospital discharge diagnosis which served as the criterion standard.ResultsOf the 264 included patients 94 (35%) had a final diagnosis of AHF. Forty total patients had a LUS performed, 17 of these patients had a final diagnosis of AHF. Sensitivity and specificity for AHF by paramedics was 23% (95% CI 0.14‐0.34) and 97% (CI 0.92‐0.99) without LUS and 71% (95% CI 0.44‐0.88) and 96% (95% CI 0.76‐0.99) with the use of LUS. In the 94 patients with AHF, 14% (11/77) received HF therapy prehospital without the use of LUS and 53% (9/17) with the use of LUS. LUS improved frequency of treatment by 39%. Median time to treatment was 21 minutes with LUS and 169 minutes without.ConclusionsLUS improved paramedic sensitivity and accuracy for diagnosing AHF in the prehospital setting. LUS use led to higher rates of prehospital HF therapy initiation and significantly decreased time to treatment.

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Early intravenous nitroglycerin use in prehospital setting and in the emergency department to treat patients with acute heart failure: Insights from the EAHFE Spanish registry

Cited by 6 publications

References 22 publications

Safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema: A 4‐year review

Safety of prehospital intravenous bolus dose nitroglycerin in patients with acute pulmonary edema: A 4‐year review

Evaluation of the effect of intravenous nitroglycerine on short-term survival of patients with acute heart failure according to congestion and perfusion status at emergency department arrival

Prehospital lung ultrasound in acute heart failure: Impact on diagnosis and treatment

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