Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods
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To date, treatment with intravenous (IV) agents such as vasodilators, diuretics, and inotropes has shown marginal or mixed benefits in acute heart failure (AHF) trials. The aim of this study was to identify the risks and benefits of IV drugs in patients hospitalized with acute decompensated heart failure.
The AHF global survey of standard treatment (ALARM-HF) reviewed in-hospital treatments in eight countries. The present study was a post hoc analysis of ALARM-HF data in which propensity scoring was used to identify groups of patients who differed by treatment but had the same multivariate distribution of covariates. Such propensity matching allowed estimations of the effect of specific treatments on the outcome of in-hospital mortality.
Unadjusted analysis showed a lower in-hospital mortality rate in AHF patients receiving “diuretics + vasodilators” (n = 1,805) compared to those receiving “diuretics alone” (n = 2,362) (7.6 vs. 14.2%, p < 0.0001). Propensity-based matching (n = 1,007 matched pairs) confirmed the lower mortality of AHF patients receiving diuretics + vasodilators: 7.8 versus 11.0% (p = 0.016). Unadjusted analysis showed a much greater in-hospital mortality rate in patients receiving IV inotropes (25.9%) compared to those who did not (5.2%) (p < 0.0001). Propensity-based matching (n = 954 pairs) confirmed that IV catecholamine use was associated with 1.5-fold increase for dopamine or dobutamine use and a >2.5-fold increase for norepinephrine or epinephrine use.
In terms of in-hospital survival, a vasodilator in combination with a diuretic fared better than treatment with only a diuretic. Catecholamine inotropes should be used cautiously as it has been seen that they actually increase the risk for in-hospital mortality.
KeywordsAcute heart failure ALARM-HF data Intravenous agents In-hospital survival
Acute heart failure
Systolic blood pressure
Conflict of interest
AM, JP, FVB, JFD and FF received an honorarium from Abbott for lectures and/or consulting. Abbott funded the ALARM-HF survey; data were acquired by IMS. Analyses were performed by the Département de Biostatistique et Informatique Médicale, Hôpital Saint-Louis, APHP, Université Paris 7, INSERM—UMR-S 717, Paris France by RP and EG.
- 1.Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, Stromberg A, van Veldhuisen DJ, Atar D, Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG, Swedberg K, Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL (2008) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008:the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 29:2388–2442CrossRefPubMedGoogle Scholar
- 3.Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW (2009) 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol 53:e1–e90CrossRefPubMedGoogle Scholar
- 4.Cotter G, Metzkor E, Kaluski E, Faigenberg Z, Miller R, Simovitz A, Shaham O, Marghitay D, Koren M, Blatt A, Moshkovitz Y, Zaidenstein R, Golik A (1998) Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet 351:389–393CrossRefPubMedGoogle Scholar
- 5.Sharon A, Shpirer I, Kaluski E, Moshkovitz Y, Milovanov O, Polak R, Blatt A, Simovitz A, Shaham O, Faigenberg Z, Metzger M, Stav D, Yogev R, Golik A, Krakover R, Vered Z, Cotter G (2000) High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. J Am Coll Cardiol 36:832–837CrossRefPubMedGoogle Scholar
- 8.Costanzo MR, Johannes RS, Pine M, Gupta V, Saltzberg M, Hay J, Yancy CW, Fonarow GC (2007) The safety of intravenous diuretics alone versus diuretics plus parenteral vasoactive therapies in hospitalized patients with acutely decompensated heart failure: a propensity score and instrumental variable analysis using the Acutely Decompensated Heart Failure National Registry (ADHERE) database. Am Heart J 154:267–277CrossRefPubMedGoogle Scholar
- 9.Abraham WT, Adams KF, Fonarow GC, Costanzo MR, Berkowitz RL, LeJemtel TH, Cheng ML, Wynne J (2005) In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE). J Am Coll Cardiol 46:57–64CrossRefPubMedGoogle Scholar
- 12.Follath F, Yilmaz MB, Delgado JF, Parissis JT, Porcher R, Gayat E, Burrows N, Mclean A, Vilas-Boas F, Mebazaa A (2010) Clinical presentation, management and outcomes in the Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF). Intensive Care Med (in press)Google Scholar
- 15.Gayat E, Pirracchio R, Resche-Rigon M, Mebazaa A, Mary JY and Porcher R (2010) Propensity scores in intensive care and anaesthesiology literature: a systematic review. Intensive Care Med. doi: 10.1007/s00134-010-1991-5
- 19.Follath F, Cleland JG, Just H, Papp JG, Scholz H, Peuhkurinen K, Harjola VP, Mitrovic V, Abdalla M, Sandell EP, Lehtonen L (2002) Efficacy and safety of intravenous levosimendan compared with dobutamine in severe low-output heart failure (the LIDO study): a randomised double-blind trial. Lancet 360:196–202CrossRefPubMedGoogle Scholar
- 24.Metra M, Nodari S, D’Aloia A, Muneretto C, Robertson AD, Bristow MR, Dei Cas L (2002) Beta-blocker therapy influences the hemodynamic response to inotropic agents in patients with heart failure: a randomized comparison of dobutamine and enoximone before and after chronic treatment with metoprolol or carvedilol. J Am Coll Cardiol 40:1248–1258CrossRefPubMedGoogle Scholar
- 28.Rusterholtz T, Bollaert PE, Feissel M, Romano-Girard F, Harlay ML, Zaehringer M, Dusang B, Sauder P (2008) Continuous positive airway pressure vs. proportional assist ventilation for noninvasive ventilation in acute cardiogenic pulmonary edema. Intensive Care Med 34:840–846CrossRefPubMedGoogle Scholar
- 30.Mebazaa A, Gheorghiade M, Pina IL, Harjola VP, Hollenberg SM, Follath F, Rhodes A, Plaisance P, Roland E, Nieminen M, Komajda M, Parkhomenko A, Masip J, Zannad F, Filippatos G (2008) Practical recommendations for prehospital and early in-hospital management of patients presenting with acute heart failure syndromes. Crit Care Med 36:S129–S139CrossRefPubMedGoogle Scholar
- 37.Ahmed A, Husain A, Love TE, Gambassi G, Dell’Italia LJ, Francis GS, Gheorghiade M, Allman RM, Meleth S, Bourge RC (2006) Heart failure, chronic diuretic use, and increase in mortality and hospitalization: an observational study using propensity score methods. Eur Heart J 27:1431–1439CrossRefPubMedGoogle Scholar