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      Impact of Early Initiation of Intravenous Therapy for Acute Decompensated Heart Failure on Outcomes in ADHERE

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          Background: Since most acute decompensated heart failure (ADHF) patients present for hospital care via the emergency department (ED), we sought to determine the impact of early ED initiation of ADHF-specific therapy, as indicated by nesiritide use, on subsequent outcomes. Methods: We queried the Acute Decompensated Heart Failure National Registry (ADHERE®) to identify patients with initial systolic blood pressure >90 mm Hg and negative cardiac biomarkers, hospitalized after presentation to the ED, who received nesiritide but no other intravenous vasoactive drugs. Intensive care unit use and total hospital length of stay were compared based on the hospital unit where nesiritide therapy was initiated after multivariate adjustment for baseline differences in study populations. Results: Nesiritide was started in the ED in 1,613 patients (EDN group) and after admission to an inpatient unit in 2,687 patients (INN group). EDN patients had higher baseline systolic and diastolic blood pressure (both p < 0.001); while INN patients were more likely to be male and have baseline renal dysfunction (both p < 0.001). Nesiritide was initiated a median of 2.8 and 15.5 h after presentation in EDN and INN patients, respectively (p < 0.001). Compared to INN, EDN patients had a shorter adjusted mean total hospital length of stay (5.4 vs. 6.9 days; p < 0.001), were less likely to require transfer to the intensive care unit from another inpatient unit (odds ratio [OR]: 0.301; 95% confidence interval [CI]: 0.206–0.440), and were more likely to be discharged home (OR: 1.154; 95% CI: 1.005–1.325). Conclusions: Initiation of ADHF-specific therapy early, while the patient is in the ED, is associated with improved clinical outcomes.

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          Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry.

          Quality-of-care indicators have been developed for patients hospitalized with heart failure. However, little is known about current rates of conformity with these indicators or their variability across hospitals. Data from 81 142 admissions occurring between July 1, 2002, and December 31, 2003, at 223 academic and non-academic hospitals in the United States participating in the Acute Decompensated Heart Failure National Registry (ADHERE) were analyzed. Rates of conformity with the 4 Joint Commission on Accreditation of Healthcare Organizations core performance measures--discharge instructions (HF-1), assessment of left ventricular function (HF-2), use of angiotensin-converting enzyme inhibitors in patients with left ventricular systolic dysfunction (HF-3), and smoking cessation counseling (HF-4)--as well as length of stay and in-hospital mortality rates were computed. Across all hospitals, the median rates of conformity with HF-1, HF-2, HF-3, and HF-4 were 24.0%, 86.2%, 72.0%, and 43.2%, respectively. Rates of conformity at individual hospitals varied from 0% to 100%, with statistically significant differences between academic and non-academic hospitals. Statistically significant positive independent predictors of overall conformity included the prevalence of comorbidities and the use of more intense pharmacologic management. Median hospital length of stay varied from 2.3 to 9.5 days, and in-hospital mortality varied from 0% to 11.1%. Among hospitals providing care for patients with heart failure, there is significant individual variability in conformity to quality-of-care indicators and clinical outcomes and a substantial gap in overall performance. Establishing educational initiatives and quality improvement systems to reduce this variability and eliminate this gap would be expected to substantially improve the care of these patients.
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            Intravenous Nesiritide vs Nitroglycerin for Treatment of Decompensated Congestive Heart Failure

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              Nesiritide in congestive heart failure associated with acute coronary syndromes: a pilot study of safety and efficacy.

              To compare the safety and efficacy of nesiritide versus intravenous nitroglycerin (NTG) in patients with acute coronary syndromes enrolled in the Vasodilation in the Management of Acute Congestive heart failure trial. Methods and results Retrospective review of Vasodilation in the Management of Acute Congestive heart failure trial data for heart failure associated with prospectively diagnosed acute coronary syndromes. Sixty-one patients were included; 34 received nesiritide and 27 received NTG. Pulmonary capillary wedge pressure was measured in right heart-catheterized patients (11 nesiritide, 9 NTG). Death at 6 months occurred in 2 nesiritide and 5 NTG patients (P>.2). Hypotension occurred in 4 nesiritide and 3 NTG patients (P>.6). At 24 hours, pulmonary capillary wedge pressure improvements persisted (P=.001) in the nesiritide group, whereas the NTG group had returned to baseline (P>.1). In non-right heart-catheterized patients, 24-hour dyspnea scores were at least moderately improved in all nesiritide and 71% of NTG (P=.031). At least minimal dyspnea improvement was seen in 100% of nesiritide versus 71% of NTG patients (P>.3), and 6-hour global clinical scores were at least moderately better in 75% of nesiritide versus 32% of NTG (P=.031). In non-right heart-catheterized patients, there were no 30-day readmissions with nesiritide versus 17% with NTG (P>.2).

                Author and article information

                S. Karger AG
                December 2006
                31 May 2006
                : 107
                : 1
                : 44-51
                aDepartment of Emergency Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, bAhmanson-UCLA Cardiomyopathy Center, Los Angeles, Calif., cDepartment of Emergency Medicine, Case Western Reserve University, Cleveland, Ohio, dThe Ohio State University, Columbus, Ohio, and eScios Inc., Fremont, Calif., USA
                93612 Cardiology 2007;107:44–51
                © 2007 S. Karger AG, Basel

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                Figures: 2, Tables: 3, References: 10, Pages: 8
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