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Kaddoura R, Patel A, Arabi AR. Revisiting nitrates use in pre-shock state of contemporary cardiogenic shock classification. Front Cardiovasc Med 2024; 10:1173168. [PMID: 38239875 PMCID: PMC10794683 DOI: 10.3389/fcvm.2023.1173168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 11/01/2023] [Indexed: 01/22/2024] Open
Abstract
Patients at each shock stage may behave and present differently with a spectrum of shock severity and adverse outcomes. Shock severity, shock aetiology, and several factors should be integrated in management decision-making. Although the contemporary shock stages classification provided a standardized shock severity assessment, individual agents or management strategy has not yet been studied in the context of each shock stage. The pre-shock state may comprise a wide range of presentations. Nitrate therapy has potential benefit in myocardial infarction and acute heart failure. Herein, this review aims to discuss the potential use of nitrate therapy in the context of the pre-shock state or stage B of the contemporary shock classification given its various presentations.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Patel
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Rahman Arabi
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Freund Y, Cachanado M, Delannoy Q, Laribi S, Yordanov Y, Gorlicki J, Chouihed T, Féral-Pierssens AL, Truchot J, Desmettre T, Occelli C, Bobbia X, Khellaf M, Ganansia O, Bokobza J, Balen F, Beaune S, Bloom B, Simon T, Mebazaa A. Effect of an Emergency Department Care Bundle on 30-Day Hospital Discharge and Survival Among Elderly Patients With Acute Heart Failure: The ELISABETH Randomized Clinical Trial. JAMA 2020; 324:1948-1956. [PMID: 33201202 PMCID: PMC7672513 DOI: 10.1001/jama.2020.19378] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Clinical guidelines for the early management of acute heart failure in the emergency department (ED) setting are based on only moderate levels of evidence, with subsequent low adherence to these guidelines. OBJECTIVE To test the effect of an early guideline-recommended care bundle on short-term prognosis in older patients with acute heart failure in the ED. DESIGN, SETTING, AND PARTICIPANTS Stepped-wedge cluster randomized trial in 15 EDs in France of 503 patients 75 years and older with a diagnosis of acute heart failure in the ED from December 2018 to September 2019 and followed up for 30 days until October 2019. INTERVENTIONS A care bundle that included early intravenous nitrate boluses; management of precipitating factors, such as acute coronary syndrome, infection, or atrial fibrillation; and moderate dose of intravenous diuretics (n = 200). In the control group, patient care was left to the discretion of the treating emergency physician (n = 303). Each center was randomized to the order in which they switched to the "intervention period." After the initial 4-week control period for all centers, 1 center entered in the intervention period every 2 weeks. MAIN OUTCOMES AND MEASURES The primary end point was the number of days alive and out of hospital at 30 days. Secondary outcomes included 30-day all-cause mortality, 30-day cardiovascular mortality, unscheduled readmission, length of hospital stay, and kidney impairment. RESULTS Among 503 patients who were randomized (median age, 87 years; 298 [59%] women), 502 were analyzed. In the intervention group, patients received a median (interquartile range) of 27.0 (9-54) mg of intravenous nitrates in the first 4 hours vs 4.0 (2.0-6.0) mg in the control group (adjusted difference, 23.8 [95% CI, 13.5-34.1]). There was a significantly higher percentage of patients in the intervention group treated for their precipitating factors than in the control group (58.8% vs 31.9%; adjusted difference, 31.1% [95% CI, 14.3%-47.9%]). There was no statistically significant difference in the primary end point of the number of days alive and out of hospital at 30 days (median [interquartile range], 19 [0- 24] d in both groups; adjusted difference, -1.9 [95% CI, -6.6 to 2.8]; adjusted ratio, 0.88 [95% CI, 0.64-1.21]). At 30 days, there was no significant difference between the intervention and control groups in mortality (8.0% vs 9.7%; adjusted difference, 4.1% [95% CI, -17.2% to 25.3%]), cardiovascular mortality (5.0% vs 7.4%; adjusted difference, 2.1% [95% CI, -15.5% to 19.8%]), unscheduled readmission (14.3% vs 15.7%; adjusted difference, -1.3% [95% CI, -26.3% to 23.7%]), median length of hospital stay (8 d in both groups; adjusted difference, 2.5 [95% CI, -0.9 to 5.8]), and kidney impairment (1% in both groups). CONCLUSIONS AND RELEVANCE Among older patients with acute heart failure, use of a guideline-based comprehensive care bundle in the ED compared with usual care did not result in a statistically significant difference in the number of days alive and out of the hospital at 30 days. Further research is needed to identify effective treatments for acute heart failure in older patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03683212.
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Affiliation(s)
- Yonathan Freund
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique – Hôpitaux de Paris (APHP), Paris, France
| | - Marine Cachanado
- Clinical Research Platform (URC-CRC-CRB), Hôpital Saint-Antoine, APHP, Paris, France
| | - Quentin Delannoy
- Emergency Department, Hôpital Pitié-Salpêtrière, Assistance Publique – Hôpitaux de Paris (APHP), Paris, France
| | - Said Laribi
- Emergency Department, Hôpital Bretonneau, Tours, France
| | - Youri Yordanov
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Emergency Department, Hôpital Saint Antoine, APHP, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, UMR-S 1136, Paris, France
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, APHP, Bobigny, France
| | - Tahar Chouihed
- Emergency Department, Hôpital CHRU Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre les Nancy, France
| | | | | | | | | | | | - Mehdi Khellaf
- Emergency Department, Hôpital Henri Mondor, APHP, Université Paris Est – INSERM U955, Créteil, France
| | - Olivier Ganansia
- Emergency Department, Hôpital Paris Saint Joseph, Groupe Hospitalier Paris Saint Joseph
| | - Jérôme Bokobza
- Emergency Department, Hôpital Cochin, APHP, Paris, France
| | - Frédéric Balen
- Emergency Department, Centre hospitalier Universitaire de Toulouse, Toulouse, France
| | - Sebastien Beaune
- Emergency Department, Hôpital Ambroise-Paré, APHP, Boulogne, Inserm U1144, Université de Paris, France
| | - Ben Bloom
- Emergency Department, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Tabassome Simon
- Sorbonne Université, Improving Emergency Care FHU, Paris, France
- Clinical Research Platform (URC-CRC-CRB), Hôpital Saint-Antoine, APHP, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, Hôpitaux Universitaires Saint Louis Lariboisière, FHU PROMICE INI-CRCT, AP-HP, France
- Université de Paris, Paris, France
- U942 – MASCOT- Inserm, Paris, France
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Freund Y, Gorlicki J, Cachanado M, Salhi S, Lemaître V, Simon T, Mebazaa A. Early and comprehensive care bundle in the elderly for acute heart failure in the emergency department: study protocol of the ELISABETH stepped-wedge cluster randomized trial. Trials 2019; 20:95. [PMID: 30704508 PMCID: PMC6357377 DOI: 10.1186/s13063-019-3188-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/09/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Acute heart failure (AHF) is one of the most common diagnoses for elderly patients in the emergency department (ED), with an admission rate above 80% and 1-month mortality around 10%. The European guidelines for the management of AHF are based on moderate levels of evidence, due to the lack of randomized controlled trials and the scarce evidence of any clinical added value of a specific treatment to improve outcomes. Recent reports suggest that the very early administration of full recommended therapy may decrease mortality. However, several studies have highlighted that elderly patients often received suboptimal treatment. Our hypothesis is that an early care bundle that comprises early and comprehensive management of symptoms, along with prompt detection and treatment of precipitating factors should improve AHF outcome in elderly patients. METHODS/DESIGN ELISABETH is a stepped-wedge, cluster randomized controlled, clinical trial in 15 emergency departments in France recruiting all patients aged 75 years and older with a diagnosis of AHF. The tested intervention is a care bundle with a checklist that mandates detection and early treatment of AHF precipitating factors, early and intensive treatment of congestion with intravenously administered nitrate boluses, and application of other recommended treatment (low-dose diuretics, non-invasive ventilation when indicated, and preventive low-molecular-weight heparin). Each center is randomized to the order in which they will switch from a "control period" to an "intervention period." All centers begin the trials with the control period for 2 weeks, then after each 2-week step a new center will enter the intervention period. At the end of the trial, all clusters will receive the intervention regimen. The primary outcome is the number of days alive and out of the hospital at 30 days. DISCUSSION If our hypothesis is confirmed, this trial will strengthen the level of evidence of AHF guidelines and stress the importance of the associated early and comprehensive treatment of precipitating factors. This trial could be the first to report a reduction in short-term morbidity and mortality in elderly AHF patients. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03683212. Prospectively registered on 25 September 2018.
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Affiliation(s)
- Yonathan Freund
- Sorbonne Université, Paris, France
- Emergency Department, Hôpital Pitié-Salpêtrière, Paris, France
- Service d’accueil des urgences, Hôpital Pitié-Salpêtrière, 83 boulevard de l’hôpital, 75013 Paris, France
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - Marine Cachanado
- Clinical Research Platform, Hôpital Saint-Antoine, Paris, France
| | - Sarah Salhi
- Clinical Research Platform, Hôpital Saint-Antoine, Paris, France
| | - Vanessa Lemaître
- Clinical Research Platform, Hôpital Saint-Antoine, Paris, France
| | - Tabassome Simon
- Sorbonne Université, Paris, France
- Clinical Research Platform, Hôpital Saint-Antoine, Paris, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care Medicine, Saint Louis and Lariboisière University Hospitals and INSERM UMR-S 942, Paris, France
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Chambord J, Attivi D, Thuus V, Zeghmouli C, Gibaud S. The effect of intravenous isosorbide dinitrate in acute decompensated heart failure in hospital. Int J Clin Pharm 2017; 39:536-541. [PMID: 28374342 DOI: 10.1007/s11096-017-0459-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/25/2017] [Indexed: 12/14/2022]
Abstract
Background According to new recommendations for the management of acute decompensated heart failure (ADHF) in 2015, intravenous vasodilator therapy might be given as an early therapy when systolic blood pressure is normal to high (≥110 mmHg). Only 29% of patients with ADHF are treated with vasodilators without medical contraindication. Objective To evaluate the effect of the systematic use of ISDN on ADHF without contraindication especially on rehospitalization rate. Settings The 600-bed hospital (Centre Hospitalier de l'Ouest Vosgien, Neufchâteau, France). Methods This is a retrospective study with data analysed from medical records. Patients with ADHF episodes and hospitalization in the cardiology department or intensive care unit (ICU) between November 2013 and December 2015 were included resulting in 199 hospitalizations in the analysis (37 were treated by ISDN, and 162 were not). Main outcome measure Effects of ISDN on 180-day hospital readmission for ADHF or acute myocardial infarction (AMI), in-hospital mortality, length of stay, number of ICU admissions, and ICU length of stay. Results Patients who received ISDN required more ICU admissions than the other patients (54.1 vs 33.3%, p = 0.02). Nevertheless 180-day hospital readmission was lower for patients who were receiving ISDN (8.1 vs 22.8%, p = 0.04). ISDN did not influence other clinical outcomes tested. Conclusion ISDN may minimize or prevent the consequences of altered haemodynamics. Lower rehospitalization rate with ISDN was seen in this study.
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Affiliation(s)
- Jérémy Chambord
- Department of Pharmacy, Centre hospitalier de l'Ouest Vosgien (CHOV), 1280 avenue de la division Leclerc, 88300, Neufchâteau, France
| | - David Attivi
- Department of Pharmacy, Centre hospitalier de l'Ouest Vosgien (CHOV), 1280 avenue de la division Leclerc, 88300, Neufchâteau, France
| | - Véronique Thuus
- Department of Cardiology, Centre hospitalier de l'Ouest Vosgien (CHOV), 1280 avenue de la division Leclerc, 88300, Neufchâteau, France
| | - Claire Zeghmouli
- Department of Pharmacy, Centre hospitalier de l'Ouest Vosgien (CHOV), 1280 avenue de la division Leclerc, 88300, Neufchâteau, France
| | - Stéphane Gibaud
- Department of Pharmacy, Centre hospitalier de l'Ouest Vosgien (CHOV), 1280 avenue de la division Leclerc, 88300, Neufchâteau, France. .,EA3452/CITHEFOR, Faculté de pharmacie, Université de Lorraine, 5, rue Albert Lebrun, 54000, Nancy, France. .,Pharmacie Clinique, Faculté de Pharmacie, Université de Lorraine, 5, rue Albert Lebrun, 54000, Nancy, France.
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