Outcomes Associated with Vasoactive Therapy in Patients with Acute Decompensated Heart Failure

Abstract

Study Objectives. To describe the clinical management of acute decompensated heart failure (ADHF) in patients receiving intravenous treatment with dobutamine, milrinone, or nesiritide, and to evaluate differences, based on treatment received, in the in-hospital mortality rate, length of stay (LOS), total health care costs, and 30-day hospital readmission rate. according to the vasoactive therapy received. To evaluate baseline characteristics, 2 analysis was used; logistic regression was employed to assess the relationships between drug therapy and in-hospital mortality rates, and multivariate linear regression was used to assess whether drug therapy was related to LOS and total health care costs. All regression analyses controlled for age, sex, race, region of the United States where the hospital was located, primary payer for the hospital stay, UHC patient severity class, and chronic renal failure. In-hospital mortality rates were 10.2%, 7.9%, and 2.9% in the dobutamine, milrinone, and nesiritide groups, respectively. This resulted in an adjusted odds ratio for death of 3.5 (95% confidence interval [CI] 1.8-6.8) for dobutamine and 3.9 (95% CI 1.8-8.3) for milrinone (p<0.0001). Compared with inotropic therapy (dobutamine and milrinone), mean LOS in the hospital and the intensive care unit were lower with nesiritide (p<0.001). Total health care costs were lowest with nesiritide, but this reached statistical significance only when compared with milrinone (p<0.001). Thirty-day hospital readmission rates with dobutamine, milrinone, and nesiritide were 5.0%, 9.5%, and 3.9%, respectively (p=NS). Conclusion. Nesiritide therapy was associated with a lower in-hospital mortality rate and shorter LOS compared with dobutamine and milrinone. In addition, total health care costs with nesiritide were decreased compared with milrinone. These observations need to be validated by a randomized controlled trial.

Pharmacological and Clinical Applications of Natriuretic Peptides: Accepted Knowledges or Changing Views?

“…Subjects who received Nesiritide, in fact, underwent a significant decrease in the pulmonarycapillary wedge pressure as well as in the dyspnoea and in the general fatigue yet after a 6-hours treatment, evidencing a general amelioration of their clinical status within a 7-days treatment [63]. These data seem to be also confirmed by the studies comparing the outcome and the mortality of Nesiritide in CHF respect to other common cardiovascular drugs such as dobutamine and milrinone [64,65]. Data, in fact, evidenced that Nesiritide had a reduced mortality occurrence (2.9% respect to about 7.9% in the groups receiving dobutamine and milrinone) as well as it reduced the in-hospital time (7 days respect to 10 days required by the use of other cardiovascular drugs) [61][62][63][64][65].…”

Current treatment options for early management in acute decompensated heart failure

“…While reanalysis of the original data did not show evidence of an independent effect of nesiritide on mortality or renal failure (26), observational studies did not detect any signal of adverse impact of nesiritide on mortality outcomes (27)(28)(29). However, prospective, randomized studies to date have not been powered to determine this impact.…”

Dobutamine Therapy is Associated with Worse Clinical Outcomes Compared with Nesiritide Therapy for Acute Decompensated Heart Failure: A Systematic Review and Meta-Analysis

“…In addition, 48 studies representing non-cohort studies and studies irrelevant to dobutamine or nesiritide were excluded. In the final step, two studies without complete data were eliminated, and seven studies were selected for inclusion in the meta-analysis [33,[42][43][44][45][46][47]. Figure 1 shows the study selection process and reasons for excluding studies.…”