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Published on: June 12, 2021
Hemodynamics, diuretics, and nesiritide: a retrospective VMAC analysis.
James B Young1, Mei Cheng, Roger M Mills
1Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA. youngj@ccf.org
Clinical Cardiology
|September 11, 2009
Summary
Hypotension is not the cause of increased serum creatinine (SCr) with nesiritide. High-dose diuretics increase adverse outcomes in patients with lower pulmonary capillary wedge pressure (PCWP), suggesting cautious use.
Area of Science:
- Cardiology
- Pharmacology
- Nephrology
Background:
- Nesiritide is used for acute decompensated heart failure.
- Increases in serum creatinine (SCr) are a known side effect of nesiritide.
- Hypotension has been hypothesized as the cause of SCr elevation.
Purpose of the Study:
- To test the hypothesis that hypotension causes nesiritide-associated SCr increases.
- To evaluate the relationship between hypotension, SCr elevation, and mortality in patients receiving nesiritide.
Main Methods:
- Retrospective analysis of patients from the Vasodilation in the Management of Acute Congestive Heart Failure (VMAC) trial.
- Patients were categorized by baseline pulmonary capillary wedge pressure (PCWP) and analyzed for hypotension, SCr elevation, and mortality.
- Concomitant diuretic dose was also assessed as a factor.
Main Results:
- Patients with lower PCWP (< or = 23 mm Hg) experienced more hypotension (16% vs 7%) but similar SCr elevation (29% vs 28%) and mortality compared to those with higher PCWP (> 23 mm Hg).
- High-dose diuretics were associated with increased risk of hypotension (RR: 4.2), SCr elevation (RR: 2.6), and 6-month mortality (HR: 3.6) in patients with lower PCWP.
- Hypotension risk was significantly higher with high-dose diuretics (25% vs 6%) but not in patients without concomitant high-dose diuretic treatment.
Conclusions:
- Hypotension is not the primary cause of nesiritide-associated SCr increases.
- High-dose diuretics increase the risk of adverse outcomes, including SCr elevation and mortality, in patients with PCWP < or = 23 mm Hg.
- High-dose diuretics should be used cautiously and reserved for patients with markedly elevated PCWPs.
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