256 Early use of nesiritide in the emergency department is associated with improved outcome: An ADHERE registry analysis

Abstract

Study objectives: Most patients admitted for acute heart failure are first evaluated in the emergency department (ED). Previous analysis of data from the Acute Decompensated Heart Failure National Registry (ADHERE) showed that initiation of vasoactive therapy in the ED is associated with improved outcome compared with initiation of this therapy in the inpatient setting. This analysis compares ED versus inpatient initiation of nesiritide in acute heart failure. Methods: ADHERE contains data from 265 acute care hospitals and includes community and academic institutions. We analyzed data from patients whose initial point of care was the ED, who were then admitted for acute heart failure from October 2001 through July 2003, and who received intravenous nesiritide in the ED or after hospitalization but did not receive other intravenous vasoactive medications. Differences were compared between patients who first received nesiritide in the ED (n=803) and those whose nesiritide therapy began after admission (n=1,223) by using analysis of variance, Wilcoxon, and χ2 tests along with risk adjustment models for clinical, historical, and laboratory findings known to affect outcome. Results: Median time to initiation of nesiritide in the ED (ED initiation) was 2.7 hours compared with 18.3 hours when treatment was initiated after admission (inpatient initiation; P<.0001). Median hospital length of stay was 4.1 days with ED initiation versus 5.7 days with inpatient initiation (P<.0001). A larger percentage of patients who had inpatient initiation of nesiritide required transfer to the ICU and had prolonged length of stay (highest quartile) compared with patients who had ED initiation (9% versus 2% and 35% versus 19%, respectively; P<.0001). On a risk-adjusted basis, delay of administration of nesiritide until after admission (compared with ED initiation) meant that patients were more than 2 times as likely to have prolonged length of stay. Conclusion: Early ED intervention with nesiritide yields better outcomes compared with later inpatient initiation of nesiritide treatment. These data corroborate the growing evidence that ED management of heart failure affects outcomes and underscores the need for an aggressive, timely approach to managing acute heart failure in the ED. Study objectives: Most patients admitted for acute heart failure are first evaluated in the emergency department (ED). Previous analysis of data from the Acute Decompensated Heart Failure National Registry (ADHERE) showed that initiation of vasoactive therapy in the ED is associated with improved outcome compared with initiation of this therapy in the inpatient setting. This analysis compares ED versus inpatient initiation of nesiritide in acute heart failure. Methods: ADHERE contains data from 265 acute care hospitals and includes community and academic institutions. We analyzed data from patients whose initial point of care was the ED, who were then admitted for acute heart failure from October 2001 through July 2003, and who received intravenous nesiritide in the ED or after hospitalization but did not receive other intravenous vasoactive medications. Differences were compared between patients who first received nesiritide in the ED (n=803) and those whose nesiritide therapy began after admission (n=1,223) by using analysis of variance, Wilcoxon, and χ2 tests along with risk adjustment models for clinical, historical, and laboratory findings known to affect outcome. Results: Median time to initiation of nesiritide in the ED (ED initiation) was 2.7 hours compared with 18.3 hours when treatment was initiated after admission (inpatient initiation; P<.0001). Median hospital length of stay was 4.1 days with ED initiation versus 5.7 days with inpatient initiation (P<.0001). A larger percentage of patients who had inpatient initiation of nesiritide required transfer to the ICU and had prolonged length of stay (highest quartile) compared with patients who had ED initiation (9% versus 2% and 35% versus 19%, respectively; P<.0001). On a risk-adjusted basis, delay of administration of nesiritide until after admission (compared with ED initiation) meant that patients were more than 2 times as likely to have prolonged length of stay. Conclusion: Early ED intervention with nesiritide yields better outcomes compared with later inpatient initiation of nesiritide treatment. These data corroborate the growing evidence that ED management of heart failure affects outcomes and underscores the need for an aggressive, timely approach to managing acute heart failure in the ED.