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The effect of nitrates in patients with coronary artery disease across different left ventricular ejection fractions
Hui Liu1, Wei Liu1, Yalin Cao1
1Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China.
Insights
Long-acting nitrates are commonly prescribed for coronary artery disease (CAD). In patients with reduced left ventricular ejection fraction (LVEF <45%), nitrates were associated with worse long-term outcomes, including death and major adverse cardiovascular events.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Long-acting nitrates are frequently prescribed for coronary artery disease (CAD).
- The association between nitrate use and long-term outcomes in CAD patients is debated.
- The modifying effect of left ventricular ejection fraction (LVEF) on this association is not well understood.
Purpose of the Study:
- To investigate the association between discharge nitrate prescription and long-term outcomes in CAD patients.
- To determine if LVEF modifies the relationship between nitrate use and outcomes in CAD.
Main Methods:
- Retrospective cohort study of 2,404 adult CAD patients undergoing coronary angiography.
- Patients stratified by LVEF (<45%, 45%-55%, >55%) and nitrate prescription at discharge.
- Primary endpoint: all-cause death. Secondary endpoint: major adverse cardiovascular events (MACE).
- Kaplan-Meier and multivariable Cox regression analyses were used.
Main Results:
- Nitrate use at discharge was not associated with all-cause death or MACE in the overall cohort.
- In patients with LVEF <45%, nitrate use was associated with significantly higher risks of all-cause death (HR 2.14) and MACE (HR 1.91).
- No significant associations were observed in patients with LVEF 45%-55% or >55%.
Conclusions:
- Nitrate prescription at discharge is common in CAD patients.
- An adverse association between nitrates and long-term outcomes was observed exclusively in patients with reduced LVEF (<45%).
- Cautious use of nitrates is recommended in CAD patients with reduced LVEF, and further prospective studies are warranted.
Background:
Long-acting nitrates are widely prescribed in coronary artery disease (CAD), yet their association with long-term outcomes remains controversial. Whether left ventricular ejection fraction (LVEF) modifies this relationship has not been well characterized.
Methods:
We conducted a single-center retrospective cohort study using the Guizhou Provincial People's Hospital CAD database. Adults (≥18 years) who underwent coronary angiography between July 2012 and September 2016 and met angiographic criteria for CAD (≥50% stenosis in ≥1 proximal epicardial coronary artery) were eligible if LVEF and discharge medications were available. Patients were stratified by LVEF (<45%, 45%-55%, >55%) and by discharge prescription of any nitrate (mononitrate or dinitrate). The primary endpoint was all-cause death. The secondary endpoint was major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. Kaplan-Meier methods and multivariable Cox regression were used to evaluate associations.
Results:
Among 2,404 patients followed for 27.2 ± 13.5 months, 1,153 (48.0%) were discharged on nitrates. In the overall cohort, discharge on nitrates was not associated with all-cause death or MACE. In contrast, among patients with LVEF < 45%, nitrates at discharge were linked to higher cumulative incidences of all-cause death and MACE (log-rank P = 0.024 and 0.029, respectively) and remained independently associated after adjustment [all-cause death: hazard ratio (HR) 2.14, 95% confidence interval (CI) 1.15-3.96; MACE: HR 1.91, 95% CI 1.07-3.43]. No significant associations were observed in the LVEF 45%-55% or >55% strata.
Conclusion:
In this CAD cohort, nitrates were commonly prescribed at discharge. An adverse association with long-term outcomes was confined to patients with reduced LVEF, supporting cautious use in this subgroup and highlighting the need for prospective confirmation.
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