Is Addition of Vasodilators to Loop Diuretics of Value in the Care of Hospitalized Acute Heart Failure Patients? Real-World Evidence From a Retrospective Analysis of a Large United States Hospital Database

•Hospital billing records for 82,808 USA patients with acute heart failure are analyzed.•Treatments with IV loop diuretics alone or with nitrates or nesiritide are compared.•IV vasodilators + IV loop diuretics do not lower inpatient mortality.•IV vasodilators + IV loop diuretics do not lower rehospitalization rates.•IV vasodilators + IV loop diuretics are associated with higher inpatient costs.

BackgroundCurrent guidelines recommend the use of intravenous (IV) vasodilators in addition to IV loop diuretics for the treatment of acute heart failure (AHF) patients without hypotension. The evidence basis for these recommendations is limited.Methods and ResultsHospital billing records for 82,808 AHF patients in the United States were analyzed. Patients receiving IV loop diuretics alone were paired with patients receiving IV loop diuretics + IV nitrates or IV nesiritide with the use of propensity score matching, excluding those with hypotension and/or evidence of cardiogenic shock, myocardial infarction, or acute coronary syndrome. Compared with paired patients receiving IV loop diuretics alone, in-hospital mortality was similar among IV loop diuretics + IV nitrates patients (n = 4,401; 1.9% vs 2.0%; P = .88) and marginally higher for IV loop diuretics + IV nesiritide patients (n = 2,254; 2.2% vs 3.1%; P = .05). Compared with paired IV loop diuretics patients, IV loop diuretics + IV nitrates or IV nesiritide had longer lengths of stay (+1.6 and +2.1 days; P < .01) and 57% higher costs (P < .01).ConclusionsAmong hospitalized AHF patients, the addition of IV vasodilators to IV loop diuretics did not lower inpatient mortality or rehospitalization rates compared with loop diuretics alone, and was associated with longer lengths of stay and higher hospitalization costs. Although the lack of complete clinical, socioeconomic, and post-discharge data may have confounded these results, this analysis questions whether currently available IV vasodilators can improve outcomes in hospitalized AHF patients.