Interleukin-6 and Outcomes in Acute Heart Failure: An ASCEND-HF Substudy

BACKGROUND

The inflammatory cytokine IL-6 has been previously implicated in the pathophysiology of acute decompensated heart failure (HF). Prior observations in acute HF patients have suggested that IL-6 may be associated with outcomes and modulated by nesiritide. We aimed to evaluate the associations between serial IL-6 measurements, mortality and rehospitalization in acute HF.

METHODS AND RESULTS

We analyzed the associations between IL-6 in acute HF, readmission, and mortality (30 and 180 days) using a cohort of 883 hospitalized patients from the ASCEND-HF trial (nesiritide vs placebo). Plasma IL-6 was measured at randomization (baseline), 48-72 hours, and 30 days. The median IL-6 was highest at baseline (14.1 pg/mL) and decreased at subsequent time points (7.6 pg/mL at 30 days). In a univariable Cox regression analysis, the baseline IL-6 was associated with 30- and 180-day mortality (hazard ratio per log 1.74, 95% confidence interval 1.09-2.78, P = .021; hazard ratio 3.23, confidence interval 1.18-8.86, P = .022, respectively). However, there was no association after multivariable adjustment. IL-6 at 48-72 hours was found to be independently associated with 30-day mortality (hazard ratio 8.2, confidence interval 1.2-57.5, P= .03), but not 180-day mortality in multivariable analysis that included the ASCEND-HF risk model and amino terminal pro-B-type natriuretic peptide as covariates. In comparison with placebo, nesiritide therapy was not associated with differences in serial IL-6 levels.

CONCLUSIONS

Although elevated IL-6 levels were associated with higher all-cause mortality in acute HF, no independent association with this outcome was identified at baseline or 30-day measurements. In contrast with prior reports, we did not observe any impact of nesiritide over placebo on serial IL-6 levels.

Skeletal Dysplasias: What Every Bone Health Clinician Needs to Know

PURPOSE OF REVIEW

This review highlights how skeletal dysplasias are diagnosed and how our understanding of some of these conditions has now translated to treatment options.

RECENT FINDINGS

The use of multigene panels, using next-generation sequence technology, has improved our ability to quickly identify the genetic etiology, which can impact management. There are successes with the use of growth hormone in individuals with SHOX deficiencies, asfotase alfa in hypophosphatasia, and some promising data for c-type natriuretic peptide for those with achondroplasia. One needs to consider that a patient with short stature has a skeletal dysplasia as options for management may be available.

Unsuccessfully Treated Hypertension: A Major Public Health Problem With a Potential Solution

BACKGROUND

About one-half of all hypertensive adults do not have their blood pressure controlled. They are often prescribed medications that conform to national guidelines but they continue to have elevated blood pressure. This public health problem might be improved by applying plasma renin guided therapy.

RESULTS

A contributor to the public health problem of unsuccessfully treated hypertension is that the circulating renin-angiotensin system (RAS) is not recognized in treatment guidelines as clinically relevant for the treatment of hypertension or as important as the body salt status for determining blood pressure levels. Another contributor to the problem is the lack of specificity in the package inserts for antihypertensive drugs. They do not specifically state under the heading "Indications" that RAS blockers are primarily most effective in hypertensive subjects with medium and high plasma renin levels; by contrast, natriuretic drugs are most effective in those with low plasma renin levels.

METHODS

Literature review.

CONCLUSIONS

To address the problem of unsuccessfully treated hypertension, we recommend that the "Indications" section of package inserts for antihypertensive drugs be more specific. The primary indication for RAS blockers ought to be hypertension with medium and high plasma renin levels, and natriuretic agents for those with low plasma renin levels. Similar language ought to be added to treatment guidelines. Additionally, 3 other reasons for lack of blood pressure control also need to be addressed-failure to prescribe antihypertensive drugs to hypertensive subjects, failure of patients to fill prescriptions, and low drug adherence.

Chronic heart failure as a state of reduced effectiveness of the natriuretic peptide system: implications for therapy

Natriuretic peptides (NPs) promote diuresis, natriuresis and vasodilation in early chronic heart failure (CHF), countering renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system (SNS) overstimulation. Despite dramatic increases in circulating NP concentrations as CHF progresses, their effects become blunted. Increases in diuresis, natriuresis, and vasodilation after administration of exogenous atrial (ANP) or brain (BNP) natriuretic peptides are attenuated in patients with advanced CHF compared with controls. Several major factors may account for the reduced effectiveness of the natriuretic peptide system (NPS) in CHF. First, there is reduced availability of active forms of NPs, namely BNP. Second, target organ responsiveness becomes diminished. Third, the counter-regulatory hormones of the RAAS and SNS, and endothelin-1 become over-activated. Therefore, pharmacological approaches to enhance the functional effectiveness of the NPS in CHF have been explored in recent years. In terms of clinical outcomes, studies of synthetic BNP, or of neprilysin inhibitors alone or associated with an angiotensin converting enzyme inhibitor, have been controversial for several reasons. Recently, however, encouraging results have been obtained with the angiotensin receptor neprilysin inhibitor sacubitril/valsartan. The available data show that treatment with sacubitril/valsartan is associated with increased levels of NPs and their intracellular mediator cyclic guanosine monophosphate, suggesting improved functional effectiveness of the NPS, in addition to beneficial effects on mortality and morbidity outcomes. Therefore, combined targeting of the NPS and RAAS with sacubitril/valsartan emerges as the current optimal approach for redressing the neurohormonal imbalance in CHF.

[Novelties in the treatment of heart failure]

Heart failure (HF) is a complex clinical syndrome which is manifested by characteristic symptoms and objective signs of cardiac insufficiency. The incidence of HF, particularly its chronic form, is estimated 0.4-2 % in the central and western Europe, with an increase in higher age groups, affecting 10-20 % of the population aged over 80. With respect to its growing incidence and prevalence, novel modalities of pharmacological and non-pharmacological treatment are being developed in order to improve quality of life and survival of the affected patients. This review based on up-to-date guidelines focuses in the first part on brief description of the possibilities of diagnosing heart failure, including the novelties arising out from the latest clinical and preclinical studies (such as soluble ST2, FSTL1, etc), further it concentrates on innovations in pharmacological treatment of chronic (ivabradine, ARNI, gliflozins) and acute (ularitide, serelaxin, nesiritide) HF. The last part provides an overview of available non-pharmacological HF therapeutics options (modulation of cardiac contraction, influencing the activity of sympathetic and parasympathetic nervous systems and permanent and temporary device support).Key words: ARNI - ECMO - gliflozins - heart failure - modulation of sympathetic and parasympathetic nervous systems - sacubitril-valsartan - therapy.

Perioperative Nesiritide Versus Milrinone in High-Risk Coronary Artery Bypass Graft Patients

Background:

Patients with left-ventricular dysfunction have an increased risk of developing heart failure after coronary artery bypass graft (CABG) surgery. Therapies to maintain cardiac output in such patients warrant investigation. Nesiritide is unique among intravenous medications used to manage heart failure. It mediates natriuresis and vasodilation and suppresses the renin–angiotensin'aldosterone axis. Nesiritide may attenuate the body's neurohormonal response to myocardial stretch after CABG and provide clinical benefit in the immediate postoperative period.

Objective:

To determine whether perioperative infusion of nesiritide improves clinical outcomes compared with milrinone therapy.

Methods:

A prospective, open-label, randomized controlled trial was conducted in 40 consecutive hemodynamically stable patients with ejection fractions 35% or less undergoing CABG surgery. Patients were randomized to receive either an intraoperative bolus of nesiritide or milrinone followed by a 24 hour infusion of each agent. Length of postoperative intensive care unit stay was the primary outcome variable evaluated. Incidence of postoperative heart failure, 30 day readmission rates, mortality, and other clinical parameters were also compared.

Results:

Patients receiving nesiritide had a mean ± SD postoperative intensive care unit stay of 50.6 ± 46.8 hours compared with 44.1 ± 23.5 hours in those receiving milrinone (p = 0.578). Incidence of postoperative heart failure was also not significantly different between the drugs (p = 0.259). Thirty day follow-up confirmed no difference in hospital readmission rates between nesiritide and milrinone (p = 0.661). No differences in mortality were observed during hospitalization or 30 days of follow-up.

Conclusions:

Nesiritide does not decrease postoperative intensive care unit stay or other clinical parameters compared with milrinone in high-risk patients with hemodynamically stable left-ventricular function undergoing CABG surgery.

Nesiritide Compared with Milrinone for Cardiac Surgery

Management of patients with low cardiac output syndromes is difficult. Current therapies (ie, inotropes) have associated adverse effects and have not been shown to impact clinical outcomes such as decreased mortality or length of stay. Patients unable to recover from low cardiac output states have end organ damage, increased lengths of stay, increased hospital costs, and readmissions. Nesiritide has been suggested as an alternative or adjunct medication to treat cardiac surgery patients. Recent trials have provided information on the effects of some of these agents on clinical outcomes including respiratory failure, length of stay, and mortality.

Effect of recombinant human brain natriuretic peptide (rhBNP) versus nitroglycerin in patients with heart failure: A systematic review and meta-analysis

BACKGROUND

This study was the first to evaluate the therapeutic outcomes of recombinant human brain natriuretic peptide (rhBNP) versus nitroglycerin (NIT) in patients with heart failure (HF).

METHODS

The electronic databases were systematically searched to identify available studies. The pooled odds ratios (ORs) and their 95% confidence intervals (95% CIs) were analyzed to assess the mortality, readmission, hypotension, and renal dysfunction in the comparison of rhBNP and NIT therapies.

RESULTS

Final 5 randomized controlled trials (RCTs) involving 782 patients with HF were carried out in our study. The pooled OR of mortality, readmission, and hypotension showed that no significant difference was found in both drugs (P > 0.05), with the absence of heterogeneity. The incidence of renal dysfunction was not significant difference in both groups (P = 0.85). The pooled OR from 2 studies of Asian population using multivariate analysis demonstrated that the use of rhBNP was correlated with a significantly decreased risk of renal dysfunction (I = 0.0%, OR = 0.19, P = 0.001). Possible publication bias was not detected using Egger's test (P > 0.05).

CONCLUSIONS

The results suggested that rhBNP and NIT therapies were not significant difference in mortality, readmission, and hypotension. The use of rhBNP may become a useful predictor of renal dysfunction in Asian patients with HF. Additional studies are needed for Caucasian population with HF.

Perioperative Effects and Safety of Nesiritide Following Cardiac Surgery in Children

Nesiritide (Natrecor, Scios Inc), human B-type natriuretic peptide, has hemodynamic effects that may be beneficial in pediatric patients after cardiac surgery. Experience with nesiritide and pediatrics is limited. The purpose of this study was to evaluate perioperative effects and safety of nesiritide in pediatric cardiothoracic surgery. Seventeen patients with congenital heart disease undergoing cardiac surgery were given a loading dose (1 µg/kg) while on cardiopulmonary bypass (constant flow) followed by continuous infusion for 24 hours (0.01 µg/kg/min × 6 hours, then 0.02 µg/kg/min × 18 hours). A 7% decrease in mean blood pressure was seen following nesiritide loading dose on cardiopulmonary bypass. No patient required intervention for hypotension while receiving nesiritide load or infusion. Nesiritide load during surgery and continuous infusion after cardiac surgery in pediatric patients resulted in no significant hemodynamic compromise.

Nesiritide: Trials and Tribulations

Standard therapy for acute decompensated heart failure, a major health problem, consists of intravenous diuretics, vasodilators, and positive inotropic agents. Nesiritide, a recombinant form of human B-type natriuretic peptide, is the only drug specifically approved for this indication. Recent meta-analyses have reported an increased risk of worsening renal function and 30-day mortality with nesiritide administration. These data understandably require physicians to carefully reevaluate their current use of nesiritide in patients with acute decompensated heart failure. In performing this reevaluation, it is important to consider our understanding of the underlying disease state, the limitations and results of these meta-analyses, and new data that provide additional insight into the possible risks and benefits associated with nesiritide therapy. Until additional therapeutic trials are conducted, therapeutic choices must be based on symptomatic and hemodynamic improvement and limited, imperfect available data, which may continue to support the use of nesiritide for its established indication.

Research protocol: effect of natural S-equol on blood pressure and vascular function--a six-month randomized controlled trial among equol non-producers of postmenopausal women with prehypertension or untreated stage 1 hypertension

BACKGROUND

Although higher habitual soy intake is associated with lower blood pressure (BP) and stroke incidence, clinical trials using soy protein or isoflavones on cardiovascular risks yielded inconsistent results. The discrepancies are hypothesized to be due to the individuals' intestinal bacterial capacity to metabolite isoflavones daidzein into equol. Animal and in vitro studies have revealed that equol has stronger estrogen-like and anti-oxidative activity than isoflavones and possesses natriuretic and vasorelaxant properties which may play an important role in the prevention of hypertension. However, no clinical trial has examined the effect of equol on BP. We thus propose a 24-week randomized controlled trial to test the effectiveness of natural S-equol on BP and vascular function among equol non-producers.

METHODS/DESIGN

This will be a 6-month double-blind, randomized, placebo-controlled trial among 207 non-equol producing postmenopausal women with prehypertension or early untreated hypertension. Eligible participants who have completed a 2-week run-in will be randomized to either one of the 3 groups: placebo group, low-equol group (10 mg/d) and high equol group (20 mg/d). The outcome measures will be conducted at baseline and at the end of the trial including 24 h ambulatory BP, endothelial function (by ultrasound determined brachial flow mediated dilation), arterial stiffness (by pulse wave analysis) and other cardiovascular risk factors (lipid profile, glycemic control and inflammatory biomarkers). Urinary isoflavones will be tested for compliance assessment. One way analysis of variance will be applied to compare the 6-month changes in ambulatory BP or parameters of vascular function among the 3 treatment groups.

DISCUSSION

This study will be performed in community subjects. If the antihypertensive effect of equol is proven, the provision of natural equol to those high risk adults who are unable to produce equol will have enormous public health implications for the primary and secondary prevention of hypertension and cardiovascular diseases on a population basis. The research efforts will also have significant implications for industry in the provision of suitable soy products for the prevention of hypertension and its related complications.

TRIAL REGISTRATION

The trial was registered in ClinicalTrials.gov with identifier of NCT02515682 .

Prognostic Value of Baseline and Changes in Circulating Soluble ST2 Levels and the Effects of Nesiritide in Acute Decompensated Heart Failure

OBJECTIVES

The study sought to investigate the association between soluble growth stimulation expressed gene 2 (sST2) level and adverse outcomes in acute heart failure (HF).

BACKGROUND

Several studies have demonstrated the prognostic utility of sST2 levels in HF.

METHODS

sST2 levels were measured in sequential baseline and follow-up (48 to 72 h and 30 days) plasma samples from 858 acute HF subjects enrolled in the ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial biomarker substudy and were related to in-hospital and post-discharge clinical outcomes.

RESULTS

Higher sST2 levels were associated with increased death risk at 180 days (baseline hazard ratio [HR]: 2.21; follow-up HR: 2.64; both p < 0.001). These results were not independent of covariates and aminoterminal pro-B-type natriuretic peptide for baseline sST2 (HR: 1.29, p = 0.243), but were borderline significant for follow-up sST2 (HR: 1.61, p = 0.051). Subjects with persistently high (>60 ng/ml) sST2 levels at follow-up had higher 180-day death rates than those with lower follow-up sST2 levels (adjusted HR: 2.91, p = 0.004). Neither baseline nor follow-up sST2 levels were associated with dyspnea improvement. Changes in sST2 from baseline were less in the nesiritide versus placebo group at follow-up, but were similar at 30 days.

CONCLUSIONS

Elevated levels of sST2 were associated with an increased risk of adverse clinical events in acute HF, but prognostic value of baseline sST2 diminished after adjusting for clinical covariates and aminoterminal pro-B-type natriuretic peptide. In those with elevated baseline sST2 levels, persistently elevated sST2 levels at follow-up were associated with increased mortality risk. In addition, nesiritide did not demonstrate an incremental impact on sST2 levels over standard therapy.

Volume Overload in Heart Failure: An Evidence-Based Review of Strategies for Treatment and Prevention

Acute decompensated heart failure is the leading cause of hospital admission in the United States, with a high risk of readmission within 30 days. Most acute decompensated heart failure admissions are driven by congestive signs and symptoms resulting from fluid and sodium overload. We reviewed the evidence base addressing the management and prevention of fluid overload in heart failure, focusing on recent clinical trials. All the references in this review were obtained through PubMed and had at least 1 of the following key words: heart failure and volume overload, congestion, loop diuretics, thiazide diuretics, aldosterone antagonists, dopamine, cardiorenal syndrome, nesiritide, vasopressin antagonists, ultrafiltration, sodium restriction, fluid restriction, telemonitoring, and invasive hemodynamic monitoring. We also reviewed relevant references cited in the obtained articles, especially articles addressing methods of treating or preventing volume overload in patients with heart failure.

Novel approaches to short stature therapy

Besides growth hormone, several pharmaceutical products have been investigated for efficacy and safety in increasing short term growth or adult height. Short-term treatment with testosterone esters in boys with constitutional delay of growth and puberty is efficacious in generating secondary sex characteristics and growth acceleration. The addition of oxandrolone to growth hormone (GH) in Turner syndrome has an additive effect on adult height gain. Treatment with GnRH analogs is the established treatment of central precocious puberty, and its addition to GH therapy appears effective in increasing adult height in GH deficient children, and possibly short children born SGA or with SHOX deficiency, who are still short at pubertal onset. Aromatase inhibitors appear effective in several rare disorders, but their value in increasing adult height in early pubertal boys with GH deficiency or idiopathic short stature is uncertain. A trial with a C-natriuretic peptide analog offers hope for children with achondroplasia.

Left ventricular responses to acute changes in late systolic pressure augmentation in older adults

BACKGROUND

Changes in the cardiovascular system with age may predispose older persons to development of heart failure with preserved ejection fraction. Vascular stiffening, aortic pressure augmentation, and ventricular-vascular coupling have been implicated. We explored the potential for acute reductions in late systolic pressure augmentation to impact left ventricular relaxation in older persons without heart failure.

METHODS

Sixteen older persons free of known cardiovascular disease with the exception of hypertension had noninvasive tonometry and cardiac ultrasound to evaluate central augmentation index (AI) and diastolic function at baseline and after randomized, blinded administration of intravenous B-type natriuretic peptide (BNP) and hydralazine in a crossover design.

RESULTS

AI was significantly reduced after BNP (11.4±8.9 to -0.2±14.7%; P = 0.02) and nonsignificantly reduced after hydralazine (14.7±8.4% to 11.5±8.8%; P = 0.39). With decreased AI during BNP, a trend toward worsened myocardial relaxation by tissue Doppler imaging occurred (E' velocity pre- and post-BNP: 10.0±2.5 and 8.8±2.0cm/s, respectively; P = 0.06). There was a significant fall in stroke volume with BNP (68.5±18.3 to 60.9±18.1ml; P = 0.02), suggesting that changes in preload overwhelmed effects of afterload reduction on ventricular performance. With hydralazine, neither relaxation nor stroke volume changed.

CONCLUSIONS

Acute changes in late systolic aortic pressure augmentation do not necessarily lead to improved systolic or diastolic function in older people. Preload may be a more important determinant of cardiac performance than afterload in older people with compensated ventricular function. The potential for changes in preload to impair rather than enhance left ventricular systolic and diastolic function in older people warrants further study.

CLINICAL TRIALS REGISTRATION

This study is registered at clinicaltrials.gov as NCT00204984.

Hemodynamic optimization in high-risk mitral valve repairs as a key component in surgical readiness

Ensuring optimal readiness for surgery using a preoperative checklist has been shown to reduce perioperative morbidity and mortality in both elective and urgent surgeries. We recently introduced hemodynamic optimization as part of our preoperative preparedness strategy for cardiothoracic surgery. Here we describe the case of a patient with severe mitral regurgitation and suboptimal hemodynamics that was optimized preoperatively with nesiritide to reduce pulmonary hypertension. Postoperatively, the patient had an improvement of his heart failure from New York Heart Association functional class 3 to class 1. Without hemodynamic optimization the patient may have been considered too high-risk to undergo mitral valve repair. This case report illustrates the importance of a systemic approach with high-risk surgery, and the use of strategies that optimize key patient factors, including hemodynamics, prior to all elective and urgent procedures.

Natriuretic peptide-guided therapy in chronic heart failure: a meta-analysis of 2,686 patients in 12 randomized trials

Background

The role of cardiac natriuretic peptides in the management of patients with chronic heart failure (HF) remains uncertain. The purpose of this study was to evaluate whether natriuretic peptide-guided therapy, compared to clinically-guided therapy, improves mortality and hospitalization rate in patients with chronic HF.

Methodology/Principal Findings

MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases were searched for articles reporting natriuretic peptide-guided therapy in HF until August 2012. All randomized trials reporting clinical end-points (all-cause mortality and/or HF-related hospitalization and/or all-cause hospitalization) were included. Meta-analysis was performed to assess the influence of treatment on outcomes. Sensitivity analysis was performed to test the influence of potential effect modifiers and of each trial included in meta-analysis on results. Twelve trials enrolling 2,686 participants were included. Natriuretic peptide-guided therapy (either B-type natriuretic peptide [BNP]- or N-terminal pro-B-type natriuretic peptide [NT-proBNP]-guided therapy) significantly reduced all-cause mortality (Odds Ratio [OR]:0.738; 95% Confidence Interval [CI]:0.596 to 0.913; p = 0.005) and HF-related hospitalization (OR:0.554; CI:0.399 to 0.769; p = 0.000), but not all-cause hospitalization (OR:0.803; CI:0.629 to 1.024; p = 0.077). When separately assessed, NT-proBNP-guided therapy significantly reduced all-cause mortality (OR:0.717; CI:0.563 to 0.914; p = 0.007) and HF-related hospitalization (OR:0.531; CI:0.347 to 0.811; p = 0.003), but not all-cause hospitalization (OR:0.779; CI:0.414 to 1.465; p = 0.438), whereas BNP-guided therapy did not significantly reduce all-cause mortality (OR:0.814; CI:0.518 to 1.279; p = 0.371), HF-related hospitalization (OR:0.599; CI:0.303 to 1.187; p = 0.142) or all-cause hospitalization (OR:0.726; CI:0.609 to 0.964; p = 0.077).

Conclusions/Significance

Use of cardiac peptides to guide pharmacologic therapy significantly reduces mortality and HF related hospitalization in patients with chronic HF. In particular, NT-proBNP-guided therapy reduced all-cause mortality and HF-related hospitalization but not all-cause hospitalization, whereas BNP-guided therapy did not significantly reduce both mortality and morbidity.

Effect of nesiritide in patients with acute decompensated heart failure

BACKGROUND

Nesiritide is approved in the United States for early relief of dyspnea in patients with acute heart failure. Previous meta-analyses have raised questions regarding renal toxicity and the mortality associated with this agent.

METHODS

We randomly assigned 7141 patients who were hospitalized with acute heart failure to receive either nesiritide or placebo for 24 to 168 hours in addition to standard care. Coprimary end points were the change in dyspnea at 6 and 24 hours, as measured on a 7-point Likert scale, and the composite end point of rehospitalization for heart failure or death within 30 days.

RESULTS

Patients randomly assigned to nesiritide, as compared with those assigned to placebo, more frequently reported markedly or moderately improved dyspnea at 6 hours (44.5% vs. 42.1%, P=0.03) and 24 hours (68.2% vs. 66.1%, P=0.007), but the prespecified level for significance (P≤0.005 for both assessments or P≤0.0025 for either) was not met. The rate of rehospitalization for heart failure or death from any cause within 30 days was 9.4% in the nesiritide group versus 10.1% in the placebo group (absolute difference, -0.7 percentage points; 95% confidence interval [CI], -2.1 to 0.7; P=0.31). There were no significant differences in rates of death from any cause at 30 days (3.6% with nesiritide vs. 4.0% with placebo; absolute difference, -0.4 percentage points; 95% CI, -1.3 to 0.5) or rates of worsening renal function, defined by more than a 25% decrease in the estimated glomerular filtration rate (31.4% vs. 29.5%; odds ratio, 1.09; 95% CI, 0.98 to 1.21; P=0.11).

CONCLUSIONS

Nesiritide was not associated with an increase or a decrease in the rate of death and rehospitalization and had a small, nonsignificant effect on dyspnea when used in combination with other therapies. It was not associated with a worsening of renal function, but it was associated with an increase in rates of hypotension. On the basis of these results, nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure. (Funded by Scios; ClinicalTrials.gov number, NCT00475852.).

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.

Practice implications of recent clinical trials for the prevention of acute kidney injury in cardiovascular surgery

Acute kidney injury in patients undergoing cardiovascular surgery is a complex problem with associated increased risks for dialysis, short- and long-term mortality, and progression to end-stage renal disease. Interventions to prevent and treat renal complications in this cohort have seldom been uniformly satisfactory due to the differences in strategies for intervention, drug doses and duration of treatment, baseline renal functions, and population studied. Nonetheless, significant advances have been made and include recognition of the effect of preexisting organ dysfunction on renal outcomes, reassessment of existing therapeutic interventions, and exploration of the feasibility of newer agents to prevent and treat acute kidney injury in cardiovascular surgery patients. This article briefly reviews several of these issues with an emphasis on recent clinical trials in this cohort.

Impact of acute serum creatinine elevation in patients treated with nesiritide

BACKGROUND

We assessed the effect of increases in serum creatinine on mortality in nesiritide-treated versus control subjects with acute decompensated heart failure (ADHF).

HYPOTHESIS

Mortality effect of nesiritide-related increases in serum creatinine differs from that of standard therapies.

METHODS

Scios Inc., granted unrestricted access to data from all 5 randomized, controlled nesiritide infusion trials completed to date in patients hospitalized with ADHF. We used 2 different definitions of acute serum creatinine increase: >0.3 mg/dL and > 0.5mg/dL within 30 days of study enrollment and determined 30-day mortality risk for nesiritide-treated versus control subjects utilizing each definition.

RESULTS

A total of 1,270 subjects participated in the 5 trials. A >0.3 mg/dL increase in serum creatinine was associated with a significant increase in mortality risk in control subjects, (hazard ratio [HR]: 3.47, 95% confidence interval [CI]: 1.49-8.09) but not in nesiritide-treated subjects (HR: 1.65, 95% CI: 0.90-3.05). Results were similar for a >0.5 mg/dL increase (control HR: 5.12, 95% CI: 2.09-12.57 and nesiritide HR: 1.77, 95% CI: 0.90-3.51). In subjects with >0.3 mg/dL and >0.5 mg/dL increases in serum creatinine, respectively, the 30-day mortality odds ratios for nesiritide relative to control were 0.73 (95% CI: 0.29-1.93) and 0.52 (95% CI: 0.17-1.63) using a stratified Mantel-Haenszel analysis.

CONCLUSIONS

The impact of increased serum creatinine on mortality was attenuated in nesiritide-treated patients compared to control, suggesting that the mechanism and clinical significance of increases in serum creatinine associated with nesiritide treatment may differ from those associated with standard therapies. Further investigation is warranted.

Cardiorenal syndrome

Very often, physicians confront with patients who have concomitant heart and kidney failure. The coexistence of kidney and heart failure carries an extremely bad prognosis. The exact cause of deterioration of kidney function and the mechanism underlying this interaction are complex, multifactorial in nature, and still not completely understood. Both the heart and the kidney act in tandem to regulate blood pressure, vascular tone, diuresis, natriuresis, etc. An extension to the Guytonian model of volume and blood pressure control is proposed called cardiorenal connection. Regulating actions of Guyton's model were coupled to their extended actions on structure and function of the heart and the kidney changes in the rennin-angiotensin-aldosterone system, the imbalance between nitric oxide and reactive oxygen species, the sympathetic nervous system, and inflammation are the cardiorenal connectors to develop cardiorenal syndrome. Imbalance in this closed complex will often lead to deterioration of both cardiac and kidney function. The World Congress of Nephrology emphasized vast interrelated derangements that can occur in cardiorenal syndrome and proposed that the recent definition of cardiorenal syndrome be modified into categories whose labels reflect the likely primary and secondary pathology and time frame. For management, drugs that impair kidney function are undesirable, particularly in a population with already compromised or at risk of kidney function. In severe volume-loaded patients who are refractory to diuretics, management of cardiorenal dysfunction is challenging. In the absence of definitive clinical trials, treatment decision must be based on a combination of patient's condition and understanding of individual treatment options.

Rationale and design of the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure Trial (ASCEND-HF)

BACKGROUND

Acute decompensated heart failure (ADHF) is a major public health burden with significant mortality and morbidity. Nesiritide is a recombinantly produced intravenous formulation of human B-type natriuretic peptide that promotes vasodilation and increases salt and water excretion, which results in reduced cardiac filling pressures. Prior studies have shown that dyspnea is improved in patients with ADHF 3 hours after nesiritide infusion with significant dose-related reductions in cardiac filling pressures and systemic vascular resistance without significant arrhythmias. However, the effect of nesiritide on dyspnea at 6 or 24 hours is unknown, and no clinical outcome trials have been done to provide a reliable estimate of the effect of nesiritide on morbidity and mortality.

METHODS

The Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure trial (ASCEND-HF) is a phase III study evaluating the efficacy and safety of nesiritide in patients with ADHF. Patients hospitalized for hear failure will be randomly assigned to receive either intravenous nesiritide or matching placebo for 24 hours to 7 days. The 2 coprimary end points are (1) assessment of acute dyspnea at 6 or 24 hours and (2) death or rehospitalization for hear failure within 30 days. A total of 7,000 patients will be enrolled worldwide between 2007 and 2010.

CONCLUSIONS

The data from the ASCEND-HF trial will establish whether nesiritide safely improves acute dyspnea as well as morbidity and mortality at 30 days.

Standardizing care for acute decompensated heart failure in a large megatrial: the approach for the Acute Studies of Clinical Effectiveness of Nesiritide in Subjects with Decompensated Heart Failure (ASCEND-HF)

Acute decompensated heart failure (ADHF) is a major public health issue and remains a heterogeneous, complex, and difficult condition to manage. Although novel acute therapies are being tested in large randomized clinical trials, opportunities exist to improve the standard of care by ensuring optimal adherence to currently established evidence-based interventions for HF. Consideration of the goals of therapy and practical application of current methods to assess for clinical improvement may lead to improved patient management and possibly improved outcomes for patients with ADHF. This review provides key practical information regarding the current standard of care for patients with ADHF including the goals of therapy, management of acute and chronic medications, and discharge/transition of care planning.

Uric acid: a novel risk factor for acute kidney injury in high-risk cardiac surgery patients?

BACKGROUND

Uric acid has been reported to be a risk factor for the development of chronic kidney disease; however, no study has examined whether uric acid may confer a risk for acute kidney injury.

METHODS

We investigated the relation between serum uric acid and the incidence of postoperative acute kidney injury in patients undergoing high-risk cardiovascular surgery (cardiac valve and aneurysm surgery).

RESULTS

Following cardiovascular surgery, 18 of 58 patients (31%) developed acute kidney injury, with 11 of 24 (45.8%) in the elevated uric acid group (defined as >6 mg/dl) and 7 of 34 (20.5%) in the normal uric acid group (p = 0.05). After controlling for baseline renal function, left ventricular ejection fraction, use of nesiritide, type of surgery, and history of previous surgery, an elevated preoperative uric acid conferred a 4-fold risk for acute kidney injury (OR: 3.98, CI: 1.10-14.33, p = 0.035) and longer hospital stay (36.35 vs. 24.66 days, p = 0.009).

CONCLUSION

This preliminary study suggests that uric acid may be a novel risk factor for acute kidney injury in patients undergoing high-risk cardiovascular surgery.

Nesiritide in the initial management of acute decompensated congestive heart failure

BACKGROUND

In the era of evolving therapy for heart failure (HF), optimal medical therapy has become challenging. Nesiritide is being used for HF therapy but its impact is still controversial.

METHODS

Prospective and randomized controlled study of 34 patients who presented to the emergency department (ED) with HF and remained symptomatic despite maximal standard therapy delivered for at least one hour. All patients had B-type natriuretic peptide BNP >100 pg/dl. Patients were randomized into Group A which received maximal standard therapy and group B which received nesiritide bolus followed by an infusion (0.01 mcg/kg/min) in addition to maximal therapy. Primary endpoints included HF hospital readmission, and hospital length of stay (LOS). Secondary endpoints included HF, cardiovascular, all-cause mortality, and adverse events. Composite risk score was designed. Results were analyzed using a logistic regression model and bootstrapping simulating approach.

RESULTS

Decrease in rehospitalizations for HF was observed during the 30 days and six-month follow-up in Group B. Earlier initiation of nesiritide therapy consistently shortened hospital LOS. Group B had a decrease in 30-day mortality but not after one year.

CONCLUSIONS

Acute HF patients who do not respond to maximal standard therapy appear to benefit from the early addition of nesiritide.

Outcomes of patients hospitalized for acute decompensated heart failure: does nesiritide make a difference?

BACKGROUND

Nesiritide is indicated in the treatment of acute decompensated heart failure. However, a recent meta-analysis reported that nesiritide may be associated with an increased risk of death. Our goal was to evaluate the impact of nesiritide treatment on four outcomes among adults hospitalized for congestive heart failure (CHF) during a three-year period.

METHODS

CHF patients discharged between 1/1/2002 and 12/31/2004 from the Adventist Health System, a national, not-for-profit hospital system, were identified. 25,330 records were included in this retrospective study. Nesiritide odds ratios (OR) were adjusted for various factors including nine medications and/or an APR-DRG severity score.

RESULTS

Initially, treatment with nesiritide was found to be associated with a 59% higher odds of hospital mortality (Unadjusted OR = 1.59, 95% confidence interval [CI]: 1.31-1.93). Adjusting for race, low economic status, APR-DRG severity of illness score, and the receipt of nine medications yielded a nonsignificant nesiritide OR of 1.07 for hospital death (95% CI: 0.85-1.35). Nesiritide was positively associated with the odds of prolonged length of stay (all adjusted ORs = 1.66) and elevated pharmacy cost (all adjusted ORs > 5).

CONCLUSION

In this observational study, nesiritide therapy was associated with increased length of stay and pharmacy cost, but not hospital mortality. Randomized trials are urgently needed to better define the efficacy, if any, of nesiritide in the treatment of decompensated heart failure.

Effect of nesiritide on renal function in patients admitted for decompensated heart failure

BACKGROUND

Studies addressing the effect of nesiritide on renal function in patients hospitalized for decompensated heart failure (HF) are limited, with conflicting results.

AIM

To study the effect of nesiritide on renal function in patients admitted for acute decompensated HF.

METHODS

We retrospectively reviewed charts of patients admitted with decompensated HF, comparing those who received nesiritide along with conventional therapy vs. those who received conventional therapy alone. Serum creatinine levels and body weight were measured on admission, and were compared with levels at day 3 to estimate deterioration in renal function. Worsening renal function (WRF) was defined as a rise in serum creatinine of > or =0.3 mg/dl from baseline, with final creatinine level >1.5 mg/dl.

RESULTS

We reviewed 206 charts (116 controls, 90 nesiritide group). WRF developed in 28/90 (31.1%) in the nesiritide group and 37/116 (31.9%) controls (p = 1.0). Mean change in creatinine in the nesiritide group was 0.15 +/- 0.37 mg/dl, compared to 0.17 +/- 0.25 mg/dl in controls (p = 0.75). Using an alternative cut-off increase in serum creatinine of > or =0.5 mg/dl, 16/90 (17.7%) patients in the nesiritide group developed WRF compared to 18/116 (15.5%) controls (p = 0.80). If WRF was defined as elevation in serum creatinine levels by > or =0.3 mg/dl anytime during hospitalization, the incidence of WRF in the nesiritide group remained similar to that of controls (42.2% vs. 41.3%, p = 0.90). On multivariate analysis, nesiritide therapy was not associated with WRF (OR 0.8, 95% CI 0.4-1.6, p = 0.48).

DISCUSSION

We failed to detect any significant risk of WRF in patients treated with nesiritide compared to conventional therapy in patients with decompensated HF during index hospitalization. Larger randomized, placebo-controlled trials are required to further elucidate the effect of nesiritide on renal function in these patients.

Heart failure

Heart failure is the most common reason for hospital admission in the United States. All nurses, regardless of their specialty, should be familiar with this clinical syndrome. This column describes the pathophysiology and treatment of heart failure.

Safety and efficacy of nesiritide in pediatric heart failure

BACKGROUND

We hypothesized that recombinant B-type natriuretic peptide (BNP) (nesiritide) could improve urine output and neurohormonal markers of heart failure without worsening renal function in pediatric patients.

METHODS AND RESULTS

We analyzed our experience involving 140 nesiritide infusions in 63 consecutive children. Serum levels of BNP and electrolytes were measured before and after therapy. Dosing was begun at 0.01 mcg.kg.min without a bolus and titrated to a maximum of 0.03 mcg.kg.min, in 0.005-mcg.kg.min increments. Blood pressure, heart rate, and heart rhythm were monitored. In a substudy, 20 patients with decompensated cardiomyopathy-related heart failure received 72 hours of nesiritide with prospective assessment of aldosterone, norepinephrine, plasma renin, and endothelin-1 levels before and after therapy. The heart rate decreased significantly (P = .001). Urine output increased significantly on Days 1 and 3 (P < or = .001 and .004, respectively). The mean serum creatinine level decreased from 1.135 to 1.007 mg/dL (P < or = .001). In the substudy, aldosterone levels decreased from 37.5 +/- 57.1 to 20.5 +/- 41.9 ng/dL (P = .005). Plasma renin, norepinephrine, and endothelin-1 levels decreased nonsignificantly. Two infusions were discontinued because of hypotension.

CONCLUSIONS

Nesiritide safely treated decompensated heart failure in children. Increased urine output reflected improving renal function. Improved neurohormonal markers were seen after 72 hours of therapy, and complications were uncommon.

Intermittent outpatient nesiritide infusion reduces hospital admissions in patients with advanced heart failure

Recombinant B-type natriuretic peptide (BNP) is a therapeutic modality in patients with decompensated congestive heart failure. Retrospectively tested are the effects of intermittent outpatient nesiritide infusion on symptoms, hospital readmission rates, endogenous BNP, and renal function in patients with advanced heart failure. Twenty-four patients in heart failure in New York Heart Association (NYHA) classes III-IV received a 6- to 8-hour intermittent nesiritide outpatient infusion (0.01 mcg/kg/min continuously intravenously) once weekly for a total duration of 3 months in addition to standard medical therapy. Data were analyzed retrospectively to compare hospital readmission rates, endogenous BNP levels, blood urea nitrogen, and creatinine levels 1 year before and up to 12 months after starting treatment. All patients tolerated nesiritide infusions well with no significant adverse events. At the end of the observation period, NYHA classes had improved 1 class in 16 patients and 2 classes in 4 patients and remained unchanged in 4 patients. There was a significant reduction in hospital readmissions within 1 year with nesiritide treatment compared with the year before (0.94 +/- 0.8 vs 3.6 +/- 2.2, P < .005). No significant changes were seen regarding endogenous BNP levels (1002 +/- 870 vs 1092 +/- 978 pg/mL, P = .95), blood urea nitrogen levels (45 +/- 28 vs 45 +/- 26 mg/dL, P = .96), and a tendency of slightly elevated creatinine levels that did not differ significantly compared with prior levels (1.76 +/- 0.85 vs 1.1 +/- 0.56 mg/dL, P = .5). Intermittent outpatient nesiritide treatment resulted in improved symptoms and reduced hospital readmission rates without a significant decline in renal function in patients with advanced heart failure but did not alter endogenous BNP levels.

Usefulness of BNP-administration in cardiac surgery: animal model

OBJECTIVE

The pharmacologic properties of Brain natriuretic peptide make it a favourable substance to use after cardiac operations. The goal of this study was to evaluate the effect of BNP following cardio-pulmonary bypass (CPB).

METHOD

Nineteen pigs were operated on using CPB. One group received BNP and the control group received placebo. A 30-minute ischemic episode was simulated. Following declamping, BNP was administered by an IV bolus, followed by an infusion for 60 minutes. Hemodynamic and clinical chemistry parameters were documented, as well as the amount of catecholamines.

RESULTS

The Cardiac output and Cardiac Index in the BNP group were significantly higher 60 minutes after ending CPB. Seven of ten animals in the control group needed catecholamines at the end of the experiment, whereas none of the animals in the BNP group did at this juncture. Creatine kinase and Lactate were significantly lower.

CONCLUSION

BNP is a well-tolerated agent that could present a new treatment option for heart failure following cardiac surgery. Hemodynamics are greatly improved with almost no need for pharmacological support.

Nesiritide for acute decompensated heart failure: does the benefit justify the risk?

Nesiritide is US Food and Drug Administration-approved for the treatment of patients with acutely decompensated heart failure who suffer from symptoms at rest or with minimal exertion. Its approval was based on a clinical development program that focused on surrogates and short-term effects on symptoms rather than clinical outcomes. The association between its use and subsequent risk of death raises the question of whether the endpoints assessed in the clinical development program were adequate, and provides the opportunity to evaluate the process of weighing risks with benefits. We conclude that with nesiritide, the risks of therapy outweigh the benefits demonstrated to date.

Safety and efficacy of nesiritide for acute decompensated heart failure: recent literature and upcoming trials

Congestive heart failure is increasing in prevalence in the United States, and associated morbidity and mortality remain high. Aggressive treatment of decompensated heart failure is associated with improved outcomes; however, therapies must be tailored to the presenting characteristics of each patient and most carry a risk of adverse events stemming from the pharmaceutical itself. Nesiritide is approved for the treatment of acutely decompensated heart failure, but aggregate data analysis has suggested that it may be associated with a risk of excess mortality and worsening renal insufficiency. We review the recent evidence regarding the efficacy and safety profile of nesiritide, and discuss upcoming trials designed to address concerns regarding safety and the comparative efficacy of nesiritide.

Rationale, design, and methods for the Transplant-Eligible MAnagement of Congestive Heart Failure (TMAC) trial: a multicenter clinical outcomes trial using nesiritide for TMAC

BACKGROUND

Urgent heart transplant candidates classified as United Network for Organ Sharing status 1B who require continuous infusions of inotropic agents for hemodynamic stability often have hemodynamic, electrical, or multisystem decompensation. This multicenter trial will study both traditional safety and efficacy parameters and the physiologic mechanisms of benefit of the addition to conventional therapy of nesiritide, a recombinant analog of brain-type natriuretic peptide, in this population.

METHODS

TMAC is a prospective, randomized, parallel, multicenter, double-blind, placebo-controlled study in patients awaiting heart transplantation who meet United Network for Organ Sharing status 1B criteria (N = 120) and receive continuous dobutamine or milrinone through a double-lumen central catheter for at least 3 consecutive days before randomization. Patients will receive standard care and continuous intravenous inotrope therapy plus a 28-day continuous infusion of nesiritide or placebo. There will be up to 6 months of follow-up. Primary efficacy end point will be days alive after treatment without renal, hemodynamic, or electrical worsening at completion. Secondary analyses will evaluate effects on hemodynamics, echocardiographic parameters, endogenous brain-type natriuretic peptide levels, modification of diet in renal disease-calculated glomerular filtration rate, and all-cause and cardiovascular mortality. Two mechanistic substudies will evaluate the effect on iohexol-determined glomerular filtration rate and assess changes in lung mechanics.

CONCLUSION

This investigation will provide key data for clinical profiles of heart transplant candidates bound to inotropic support. It will investigate the efficacy and safety (especially renal) of nesiritide and provide mechanistic insight into benefits of its use for the relief of breathlessness.

B-type natriuretic peptide in low-flow, low-gradient aortic stenosis: relationship to hemodynamics and clinical outcome: results from the Multicenter Truly or Pseudo-Severe Aortic Stenosis (TOPAS) study

BACKGROUND

The prognostic value of B-type natriuretic peptide (BNP) is unknown in low-flow, low-gradient aortic stenosis (AS). We sought to evaluate the relationship between AS and rest, stress hemodynamics, and clinical outcome.

METHODS AND RESULTS

BNP was measured in 69 patients with low-flow AS (indexed effective orifice area < 0.6 cm2/m2, mean gradient < or = 40 mm Hg, left ventricular ejection fraction < or = 40%). All patients underwent dobutamine stress echocardiography and were classified as truly severe or pseudosevere AS by their projected effective orifice area at normal flow rate of 250 mL/s (effective orifice area < or = 1.0 cm2 or > 1.0 cm2). BNP was inversely related to ejection fraction at rest (Spearman correlation coefficient r(s)=-0.59, P<0.0001) and at peak stress (r(s)=-0.51, P<0.0001), effective orifice area at rest (r(s)=-0.50, P<0.0001) and at peak stress (r(s)=-0.46, P=0.0002), and mean transvalvular flow (r(s)=-0.31, P=0.01). BNP was directly related to valvular resistance (r(s)=0.42, P=0.0006) and wall motion score index (r(s)=0.36, P=0.004). BNP was higher in 29 patients with truly severe AS versus 40 with pseudosevere AS (median, 743 pg/mL [Q1, 471; Q3, 1356] versus 394 pg/mL [Q1, 191 to Q3, 906], P=0.012). BNP was a strong predictor of outcome. In the total cohort, cumulative 1-year survival of patients with BNP > or = 550 pg/mL was only 47+/-9% versus 97+/-3% with BNP < 550 (P<0.0001). In 29 patients who underwent valve replacement, postoperative 1-year survival was also markedly lower in patients with BNP > or = 550 pg/mL (53+/-13% versus 92+/-7%).

CONCLUSIONS

BNP is significantly higher in truly severe than pseudosevere low-gradient AS and predicts survival of the whole cohort and in patients undergoing valve replacement.

Nesiritide for the treatment of pulmonary hypertension and cor pulmonale in an infant

Nesiritide is a synthetic form of B-type natriuretic peptide. It is approved for the treatment of acute exacerbations of congestive heart failure in hospitalized adult patients. It is currently under investigation for use in other settings and other patient populations. This article describes administration of nesiritide to an infant patient with severe pulmonary hypertension and cor pulmonale. No adverse reactions occurred during administration of the drug. Specifically, there was no hypertension, vomiting, arrhythmia, or changes in renal function. No changes in renal function occurred in the months subsequent to treatment. This case report illustrates that nesiritide can be safely administered to critically ill infants with pulmonary hypertension and cor pulmonale. Our patient experienced a decrease in pulmonary pressure and improved clinical condition during and after the infusion. However, further study is required to fully evaluate the safety and efficacy of nesiritide for these patients.

Controversy and Conflict in the Treatment of Acute Decompensated Heart Failure: Nesiritide as Evidence-Based Treatment

Acute decompensated heart failure poses a complex clinical challenge for the health care community. Evolving concepts of the pathophysiology and lack of consensus on appropriate outcome measures for drug approval underlie some of the current controversies about nesiritide. We outline the major controversies from the viewpoint that nesiritide should continue to be used judiciously by following its package insert recommendations and the Heart Failure Society of America's 2006 Comprehensive Heart Failure Practice Guidelines.

Controversy and Conflict in the Treatment of Acute Decompensated Heart Failure: Limited Role for Nesiritide

The use of nesiritide for acute decompensated heart failure (ADHF) has been clouded with controversy since its approval in 2001. Extensive marketing and many review articles have established this drug as a safe and superior product to current standards. However, its safety has been called into question by the results of a meta-analysis, and its superiority of important outcomes (length of stay, mortality, decreased readmission rate) has never been proved by a randomized trial against agents with similar vasodilator properties (e.g., nitroglycerin). A review of the available literature on nesiritide in the areas of mortality, renal effects, retrospective studies, use in off-label indications, length of stay, and mortality is presented and illustrates why its use should be limited or even eliminated. After review of this article, the reader should be able to answer the question--if nesiritide had never been approved for use in patients with ADHF, would we have missed it?--with a negative reply.