P218 POTENTIAL ROLE OF NITROGLYCERIN FOR DIURETIC RESISTANCE IN ACUTE DECOMPENSATED HEART FAILURE: A PROOF OF CONCEPT STUDY

Abstract

Abstract Background Congestion is a major determinant of end–organ dysfunction and diuretic resistance in acute decompensated heart failure (ADHF). Vasodilator therapy with nitroglycerin may help treat misdistribution of blood volume, reduce intra–abdominal pressure and improve end–organ function by recruiting capacitance veins. We assessed the role of intravenous nitroglycerin on top of maximal medical therapy to overcome diuretic resistance in ADHF patients. Methods This is a monocentric prospective study including patients with ADHF, systolic dysfunction (left ventricular ejection fraction [LVEF]<35%), persistent moderate–to–severe congestion and oliguria (<0.5 ml/Kg/h) despite high dose intravenous furosemide (>250 mg/die) plus a second diuretic (metolazone and/or acetazolamide). Exclusion criteria were systolic blood pressure < 90mmHg and eGFR < 20 ml/min/1.73m2. Intravenous nitroglycerin was added and uptitrated to the maximum tolerated dose while keeping the other treatments unchanged for at least 24 hours. The primary endpoint was change in urine output at 24 hours (T1) and 72 hours (T3) after nitroglycerin initiation compared to baseline (T0). Secondary endpoints were changes in central venous pressure (CVP), creatinine and total bilirubin. Results We enrolled 17 consecutive patients between March 2020 and October 2021. Mean age was 63±14 years, mean LVEF 31±15%, mean tricuspid annular plane systolic excursion 14.5±4 mm and mean eGFR 41.7±27.3 ml/min/1.73m2. 13 (76%) patients showed a cold profile; among them, 9 (69%) were on dobutamine, 5 (38%) on adrenaline and 3 (23%) on dopamine. At study enrolment all patients were receiving high dose intravenous furosemide (535±395mg/die), 8 (47%) sodium nitroprusside (0.3±0.5y/Kg/min), 9 (53%) metolazone (5mg/die) and 8 (47%) acetazolamide (250 mg/die). Urine output was significantly higher both at T1 and T3 compared to T0 (192±140ml/h vs 50±34ml/h, p < 0.001, and 153±87ml/h vs 50±34ml/h, p < 0.001, respectively; p for overall comparison<0.001). Also, a significant reduction of CVP was found at T1 and T3 compared to T0 (14±6mmHg vs 19±3mmHg, p = 0.025, and 12±5mmHg vs 19±3mmHg, p = 0.022, respectively; p for overall comparison=0.039). No significant changes of creatinine and total bilirubin were reported. Conclusions In this cohort of ADHF patients with diuretic resistance, adding nitroglycerin on top of maximal treatment yielded a potential benefit by significantly increasing hourly urine output whilst reducing CVP.