Comparison of in-hospital mortality in patients treated with nesiritide vs. other parenteral vasoactive medications for acutely decompensated heart failure: an analysis from a large prospective registry database

Background: Very little is known about the effects of standard intravenous drug therapies on in-hospital outcomes in patients with acutely decompensated heart failure. Methods: ADHERE (Acute Decompensated HEart Failure National REgistry) is a prospective, observational database of patients hospitalized with acutely decompensated heart failure (AHF). Over 250 U.S. hospitals participated, including community, tertiary, and academic medical centers. Data from the first 33,046 patients enrolled in ADHERE were analyzed. Details of medical history, clinical presentation, laboratories, medical management, and health outcomes were collected through hospital discharge medical record review. Therapies rendered were determined based on clinician judgment and not by a study protocol, so imbalances between groups in baseline characteristics that predicted mortality and the likelihood of receiving a given therapy were adjusted using multivariable regression and propensity analysis. Results: Patients receiving nesiritide (B-Type Natriuretic Peptide) during AHF hospitalization had a risk and propensity score adjusted odds ratio (OR) (95% CI, p-value) for mortality that was 0.83 (0.6–1.1, p = 0.186); 0.57 (0.42–0.76, p = 0.0001); and 0.41 (0.31–0.53, p<0.0001) compared, respectively, to patients receiving IV nitroglycerin (NTG), milrinone (MIL), and dobutamine (DOB). The greatest difference between unadjusted and adjusted mortality odds ratios occurred in the comparison of nesiritide and NTG, suggesting that patients treated with nesiritide were more severely ill at baseline than those treated with NTG (Table). Adjustments for baseline imbalances in variables predictive of mortality made little difference in the comparison of nesiritide to inotropes, indicating that patients receiving nesiritide and inotropes were similarly ill (Table). Unadjusted and adjusted OR for mortality in patients treated with nesiritide vs. IV NTG, MIL, and DOB are shown in the Table. Conclusions: In treatment of AHF, use of nesiritide is associated with significantly lower mortality compared to MIL and DOB. After disease severity adjustment, trends towards improved in-hospital survival are higher with nesiritide vs. IV NTG-treated patients. These data support use of IV vasodilators rather than positive inotropic agents for treatment of AHF. ∗AnalysisNesritide vs. NTGNesirtide vs. MilrinoneNesritide vs. DobutamineUnadjusted1.62∗p<0.00020.53∗p<0.00020.36∗p<0.0002Adjusted for Covariates SEX, AGE, BUN, SYSBP, DIABP, CR, BUN and CR0.85§p=0.2400.58∗p<0.00020.41∗p<0.0002Adjusted for Covariates and Propensity Score0.83†p=0.1860.57∗p<0.00020.51∗p<0.0002BUN = blood urea nitrogen, CR = serum creatinine, SYSBP = systolic blood pressure, DIABP = diastolic blood pressure∗ p<0.0002§ p=0.240† p=0.186 Open table in a new tab BUN = blood urea nitrogen, CR = serum creatinine, SYSBP = systolic blood pressure, DIABP = diastolic blood pressure