American Journal of Emergency Medicine 38 (2020) 1951

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Do nitrates improve survival on acute heart failure?

We have read with interest the recent article, “Role of high-dose in- travenous nitrates in hypertensive acute heart failure” by Wang et al. [1]. Here, we want to underline some important points to consider and mention from a study that supporting the article.

The role of nitrates are cornerstones of acute heart failure, however the etiology of heart failure should not be ignored. In patients with mod- erate or severe aortic valve stenosis close hemodynamic monitorisation is mandatory to avoid from Hemodynamic collapse. As well as aortic valve stenosis, any condition that can cause left ventriculary outflow tract obstruction such as hypertrophic cardiomyopathies should be carefully evaluated before the initiation of the therapy. In addition, the possible underlying cause of hypertensive acute heart failure, likewise coronary heart diseases, acute coronary syndromes and heart failure with preserved ejection fraction should be clearly identified. Finally, the risk of methemoglobinemia by high-dose nitrate infusion should be kept in mind [2].

In 2010, Breidthardt et al. have evaluated the non-invasive high dose-nitrates with sublingual and transdermal forms in emergency set- tings and they have noted the safety and efficacy of the treatment [3]. However, several studies have failed to demonstrate the effects of ni- trates on mortality. Ho et al. well demonstrated in 11,078 acute heart failure patients that the use of nitrates acutely in the emergency setting was not associated with improvement in short-term or near-term sur- vival [4]. More recently, the GALACTIC Trial have also failed to demon- strate the improvement in all-cause mortality and rehospitalization with the early intensive and sustained treatment with nitrates [5].

Nitrates are still being used as the first and main treatment agent in patients with acute heart failure. Even if significant improvement in symptoms is observed, especially at high doses, the positive results of nitrates on survival in acute heart failure have not yet been established.

References

1. Wang K, Samai K. Role of high-dose intravenous nitrates in hypertensive acute heart failure. Am J Emerg Med 2020;38(1):132-7 Jan.
2. Gibson GR, Hunter JB, Raabe Jr DS, Manjoney DL, Ittleman FP. Methemoglobinemia produced by high-dose Intravenous nitroglycerin. Ann Intern Med 1982;96(5): 615-6 May.
3. Breidthardt T, Noveanu M, Potocki M, Reichlin T, Egli P, Hartwiger S, et al. Impact of a high-dose nitrate strategy on cardiac stress in acute heart failure: a pilot study. J In- tern Med 2010;267(3):322-30 Mar.
4. Ho EC, Parker JD, Austin PC, Tu JV, Wang X, Lee DS. Impact of Nitrate use on survival in acute heart failure: a propensity-matched analysis. J Am Heart Assoc 2016 Feb 12;5

   (2) [pii: e002531].

   Kozhuharov N, Goudev A, Flores D, Maeder MT, Walter J, Shrestha S, et al, GALACTIC Investigators. Effect of a strategy of comprehensive vasodilation vs usual care on mor- tality and heart failure rehospitalization among patients with acute heart failure: the GALACTIC randomized clinical trial. JAMA 2019;322(23):2292-302. https://doi.org/ 10.1001/jama.2019.18598 Dec 17.

   Erdi Babayigit

   Kulu State Hospital, Kulu, Konya, Turkey

   ?Corresponding author.

   E-mail address: [email protected]

   Kadir Ugur Mert

   Eskisehir Osmangazi University, Faculty of Medicine, Department of

   Cardiology, Turkey

   19 January 2020

   https://doi.org/10.1016/j.ajem.2020.01.058

   0735-6757/(C) 2020