Nesiritide Administration in Patients With Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Surgery⁎⁎Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology

Projecting the effect of nesiritide on dialysis and hospital mortality in cardiac surgery patients

OBJECTIVE

To predict the effect of nesiritide on clinical outcomes based on the renal function change demonstrated in the Nesiritide Administered Peri-Anesthesia (NAPA) in patients undergoing cardiac surgery trial.

METHODS

We built a decision analytical model to replicate the NAPA trial with 1000 hypothetical patients in both nesiritide and placebo arms. The incident rates of dialysis, hospital death, and their composite were predicted based on the renal function data obtained from the NAPA trial. All analyses were further repeated for two subgroups stratified by the presence of preoperative renal dysfunction (RD).

RESULTS

The base-case analyses significantly favored nesiritide for the three clinical end points. In the total NAPA sample, the absolute risk reductions (ARRs) for dialysis, hospital death, and their composite across 100 simulated trials were 1.3%, 3.3%, and 4.1%, respectively. The improvement was more pronounced in the preoperative RD subgroup with the three ARRs of 4.1%, 7.1%, and 9.4%, respectively. The beneficial effect diminished in the normal preoperative renal function (NRF) subgroup with the three ARRs of 0.6%, 3.0%, and 3.4%, respectively. The best case analyses confirmed the robustness of the base-case results in the total NAPA sample and RD subgroup, but not in the NRF subgroup.

CONCLUSION

If the demonstrated renal preservation can be extrapolated, nesiritide may reduce dialysis and hospital death in cardiac surgery patient with preoperative RD, but to a much lesser extent or not in patients with normal preoperative renal function.

Could atrial natriuretic peptide be a useful drug therapy for high-risk patients after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether atrial natriuretic peptide (ANP) or brain natriuretic peptide (BNP) could be a useful alternative diuretic for patients post cardiac surgery. Altogether more than 250 papers were found using the reported search, of which eight RCTs represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the RCTs consistently showed a diuretic effect with increased creatinine clearance, and increased urine volume and reduced usage of conventional diuretics. Lower urea and creatinine levels were also found postoperatively and also reduced decreases in glomerular filtration rate compared to placebo, both in studies of patients with preoperatively normal renal function and those who had impaired function. In addition, two studies found a reduction in the incidence of AF, and renin/aldosterone levels were lower. The NAPA trial of 272 CABG patients with LV dysfunction was the only study to show a shorter ICU stay and reduced early mortality with nesiritide compared to placebo.