Intravenous Nesiritide vs Nitroglycerin for Treatment of Decompensated Congestive Heart Failure: A Randomized Controlled Trial

• Published in: JAMA : the journal of the American Medical Association Vol. 287; no. 12; pp. 1531 - 1540
• Main Author: Publication Committee for the VMAC Investigators (Vasodilatation in the Management of Acute CHF)
• Format: Journal Article
• Language: English
• Published: Chicago, IL American Medical Association 27.03.2002
• Subjects: Analysis of Variance; Atrial Natriuretic Factor - adverse effects; Atrial Natriuretic Factor - pharmacology; Atrial Natriuretic Factor - therapeutic use; Biological and medical sciences; Cardiotonic Agents - adverse effects; Cardiotonic Agents - pharmacology; Cardiotonic Agents - therapeutic use; Cardiovascular system; Double-Blind Method; Drug therapy; Drug Therapy, Combination; Dyspnea - drug therapy; Dyspnea - etiology; Female; Heart failure; Heart Failure - complications; Heart Failure - drug therapy; Heart Failure - physiopathology; Hemodynamics - drug effects; Humans; Infusions, Intravenous; Male; Medical research; Medical sciences; Middle Aged; Natriuretic Peptide, Brain; Nitroglycerin - adverse effects; Nitroglycerin - pharmacology; Nitroglycerin - therapeutic use; Pharmacology. Drug treatments; Prospective Studies; Pulmonary Wedge Pressure - drug effects; Statistics, Nonparametric; Vasodilator Agents - adverse effects; Vasodilator Agents - pharmacology; Vasodilator Agents - therapeutic use; Vasodilator agents. Cerebral vasodilators; Human; Heart failure; Vasodilator agent; Intravenous administration; Nesiritide; Decompensation; Cardiovascular disease; Chemotherapy; Treatment; Heart disease; Nitroglycerin; Organic nitrate; Comparative study
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.287.12.1531

CONTEXT Decompensated congestive heart failure (CHF) is the leading hospital discharge diagnosis in patients older than 65 years. OBJECTIVE To compare the efficacy and safety of intravenous nesiritide, intravenous nitroglycerin, and placebo. DESIGN, SETTING, AND PATIENTS Randomized, double-blind trial of 489 inpatients with dyspnea at rest from decompensated CHF, including 246 who received pulmonary artery catheterization, that was conducted at 55 community and academic hospitals between October 1999 and July 2000. INTERVENTIONS Intravenous nesiritide (n = 204), intravenous nitroglycerin (n = 143), or placebo (n = 142) added to standard medications for 3 hours, followed by nesiritide (n = 278) or nitroglycerin (n = 216) added to standard medication for 24 hours. MAIN OUTCOME MEASURES Change in pulmonary capillary wedge pressure (PCWP) among catheterized patients and patient self-evaluation of dyspnea at 3 hours after initiation of study drug among all patients. Secondary outcomes included comparisons of hemodynamic and clinical effects between nesiritide and nitroglycerin at 24 hours. RESULTS At 3 hours, the mean (SD) decrease in PCWP from baseline was –5.8 (6.5) mm Hg for nesiritide (vs placebo, P<.001; vs nitroglycerin, P = .03), –3.8 (5.3) mm Hg for nitroglycerin (vs placebo, P = .09), and –2 (4.2) mm Hg for placebo. At 3 hours, nesiritide resulted in improvement in dyspnea compared with placebo (P = .03), but there was no significant difference in dyspnea or global clinical status with nesiritide compared with nitroglycerin. At 24 hours, the reduction in PCWP was greater in the nesiritide group (−8.2 mm Hg) than the nitroglycerin group (−6.3 mm Hg), but patients reported no significant differences in dyspnea and only modest improvement in global clinical status. CONCLUSION When added to standard care in patients hospitalized with acutely decompensated CHF, nesiritide improves hemodynamic function and some self-reported symptoms more effectively than intravenous nitroglycerin or placebo.