Objectives: 

We investigated if the phenotypic classification of acute heart failure (AHF) based on the number of signs/symptoms of congestion and hypoperfusion at emergency department (ED) arrival identifies subgroups in which intravenous (IV) nitroglycerine (NTG) use improves short-term survival.

Methods: 

We included consecutive AHF patients diagnosed in 45 Spanish EDs, who were grouped according to phenotype severity. The main outcome was 30-day all-cause death. Propensity scores (PS) for NTG use were generated using variables associated with death. Analysis of interaction was performed in subgroups of patients based on congestion, hypoperfusion, age, sex, coronary artery disease (CAD), left ventricular ejection fraction (LVEF) and SBP.

Results: 

We analyzed 16 437 AHF patients (median = 83 years; women = 56%); 1882 received NTG (11.4%). In the whole cohort, the cumulative 30-day mortality in patients receiving NTG was higher (11.5% vs. 9.6%; unadjusted HR, 1.19; 95% CI, 1.04–1.36), but not in the PS-matched cohorts (1698 pairs of patients; 11.5% vs. 10.5%; HR, 1.10; 95% CI, 0.90–1.35). Mortality was increased in NTG-treated patients with mild congestion (HR, 2.09; 95% CI, 1.19–3.67), especially in those without hypoperfusion (HR, 2.51; 95% CI, 1.24–5.10). Interaction analysis of the PS-matched cohorts confirmed detrimental effects of NTG use in less congested patients, whereas beneficial effects were only observed in patients with decreased LVEF (<50% subgroup: HR, 0.59; 95% CI, 0.37–0.92; ≥50% subgroup: HR, 1.30; 95% CI, 0.66–2.56; P = 0.002).

Conclusion: 

Phenotypical classification of AHF based on congestion/hypoperfusion at ED arrival does not identify subgroups of patients in whom IV-NTG would decrease mortality, although it could potentially be beneficial in those with LVEF of less than 50%. This hypothesis will have to be confirmed in the future. Conversely, our results suggest that IV-NTG may be harmful in patients with only mild clinical congestion.

中文翻译：

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根据急诊到达时的充血和灌注状态评估静脉注射硝酸甘油对急性心力衰竭患者短期生存的影响

目标： 

我们调查了根据到达急诊室 (ED) 时充血和灌注不足的体征/症状数量对急性心力衰竭 (AHF) 的表型分类是否可以识别静脉注射 (IV) 硝酸甘油 (NTG) 使用改善短期生存的亚组。

方法： 

我们纳入了在 45 个西班牙急诊室诊断出的连续 AHF 患者，并根据表型严重程度进行分组。主要结果是 30 天全因死亡。NTG 使用倾向评分 (PS) 是使用与死亡相关的变量生成的。根据充血、灌注不足、年龄、性别、冠状动脉疾病（CAD）、左心室射血分数（LVEF）和收缩压对患者亚组进行相互作用分析。

结果： 

我们分析了 16 437 名 AHF 患者（中位数 = 83 岁；女性 = 56%）；1882 年获得 NTG（11.4%）。在整个队列中，接受 NTG 的患者的累积 30 天死亡率较高（11.5% vs. 9.6%；未调整的 HR，1.19；95% CI，1.04–1.36），但 PS 匹配队列中的情况并非如此（1698 对）患者比例；11.5% vs. 10.5%；HR，1.10；95% CI，0.90–1.35）。接受 NTG 治疗的轻度充血患者死亡率增加（HR，2.09；95% CI，1.19-3.67），特别是那些没有灌注不足的患者（HR，2.51；95% CI，1.24-5.10）。PS 匹配队列的交互分析证实，NTG 对充血程度较轻的患者有不利影响，而有益效果仅在 LVEF 降低的患者中观察到（<50% 亚组：HR，0.59；95% CI，0.37-0.92；≥50） % 亚组：HR，1.30；95% CI，0.66–2.56；P = 0.002）。

结论： 

基于到达急诊室时充血/低灌注的 AHF 表型分类并不能识别 IV-NTG 可以降低死亡率的患者亚组，尽管它可能对 LVEF 低于 50% 的患者有益。这个假设未来必须得到证实。相反，我们的结果表明 IV-NTG 对于仅有轻度临床充血的患者可能有害。