Elsevier

Journal of Cardiac Failure

Volume 27, Issue 10, October 2021, Pages 1053-1060
Journal of Cardiac Failure

Captopril Versus Hydralazine-Isosorbide Dinitrate Vasodilator Protocols in Patients With Acute Decompensated Heart Failure Transitioning From Sodium Nitroprusside

https://doi.org/10.1016/j.cardfail.2021.05.007Get rights and content

ABSTRACT

Background

The role of oral vasodilators in the management of acute decompensated heart failure (ADHF) is not clearly defined. We evaluated the use of captopril vs hydralazine-isosorbide dinitrate (H-ISDN) in the transition from sodium nitroprusside (SNP) in patients with ADHF.

Methods and Results

A retrospective chart review was performed of 369 consecutive adult patients in the intensive care unit with ADHF and reduced ejection fraction, who received either a captopril or an H-ISDN protocol to transition from SNP. Captopril patients were matched 1:2 to H-ISDN patients, based on serum creatinine and race (Black vs non-Black). Baseline demographics, serum chemistry and use of angiotensin converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) were similar in both groups. Time to SNP discontinuation (46.9 vs 40.4 hours, P = 0.11) and length of hospital stay (9.86 vs 7.99 days, P = 0.064) were similar in both groups. Length of hospital stay in the intensive care unit was statistically shorter in the H-ISDN group (4.11 vs 3.96 days, P = 0.038). Fewer H-ISDN protocol patients were discharged on ACEis/ARBs (82.9 % vs 69.9%, P = 0.003) despite similar kidney function at time of discharge (serum creatinine 1.1 vs 1.2, P = 0.113). No difference was observed in rates of readmission (40.7% vs 50%, P = 0.09) or mortality (16.3% vs 17.5 %, P = 0.77) at 1 year postdischarge.

Conclusion

Similar inpatient and 1-year outcomes were observed between patients using H-ISDN vs ACEi when transitioning from SNP, even though fewer H-ISDN protocol patients were discharged taking ACEis/ARBs despite similar kidney function.

Section snippets

Study Population

A single-center, retrospective chart review of consecutive adult patients (≥18 years of age) with New York Heart Association class III--IV symptoms who were admitted to the HFICU with ADHF requiring intravenous vasodilator therapy between the periods of July 1, 2010, and July 31, 2016, was completed. Patients were included if they had a left ventricular (LV) ejection fraction of ≤40% and were initiated on predefined captopril or H-ISDN protocols (Table 1) following hemodynamic stabilization

Results

Of a total of 783 patients screened, 369 patients met the inclusion criteria and were able to be matched (Fig. 1, STROBE diagram). These patients were matched 1:2 based on race (Black vs non-Black) and SCr categories on the day of protocol initiation (SCr <1.5, 1.5–2.4, ≥2.5). SCr was statistically significantly higher at 3 time points (admission, protocol initiation and SNP discontinuation) in the H-ISDN vs the captopril group. While the resultant SCr distribution between the matched groups

Discussion

This study has 3 significant findings regarding vasodilator weaning in patients with low cardiac output. First, there was no difference in time to wean from SNP, hospital length of stay, or mortality or hospitalization at 1 year postdischarge between using either a captopril or an H-ISDN vasodilator protocol in an ICU setting. Second, more patients who were treated with the captopril protocol in the ICU were discharged on ACEi/ARB therapy compared to those who received the H-ISDN protocol

Conclusion

Administration of ACEi or H-ISDN to patients in the ICU with low cardiac output resulted in a similar time required to wean from SNP and no difference in readmission or mortality at 1 year postdischarge based on the vasodilator group selected. Patients who were prescribed H-ISDN were less likely to receive ACEis/ARBs at discharge despite similar discharge renal function between groups.

Disclosures

Dr. Tang is a consultant for Sequana Medical, Owkin, Relypsa, and PreCardiac, has received honoraria from Springer Nature for authorship/editorship and the American Board of Internal Medicine for exam writing committee participation, all unrelated to the subject and contents of this article. Dr. Perez is a consultant at Abiomed and is currently employed by Anthem. This manuscript does not represent the views or policies of Anthem. Dr. Perez was previously employed by Cleveland Clinic at the

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