In hospitalized patients with acute heart failure (HF), the vasodilator sodium nitroprusside is a safe, effective treatment when added to standard therapy, particularly in individuals with a dilated left ventricle, for achievement of rapid decongestion and hemodynamic improvement. These findings were published in the International Journal of Cardiology.

A multicenter, retrospective cohort study (ClinicalTrials.gov Identifier: NCT05027360) was conducted among patients consecutively admitted for acute HF at 2 Italian centers. Investigators sought to explore the effectiveness, as observed by reduction in N-terminal pro-B natriuretic peptide (NT-proBNP) values, and safety of treatment with sodium nitroprusside, to examine the impact of reduction in NT-proBNP levels on the short-term and mid-term clinical endpoints (overall mortality and hospitalization for HF) and to identify potential predictors of clinical response to sodium nitroprusside treatment.

The primary study endpoint was a 25% or higher reduction in NT-proBNP levels from baseline within 48 hours of sodium nitroprusside infusion initiation. Secondary and safety endpoints included all-cause mortality; rehospitalization for HF at 1 month, 3 months, and 6 months; length of stay (LOS) in hospital; and severe hypotension.


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A total of 200 patients were enrolled in the study. Sodium nitroprusside infusion was initiated within 24 hours of hospital admission at a low dose (0.1-0.2 μg/kg/min) and titrated to a target mean arterial pressure of 65 to 75 mm Hg.  The median maximal sodium nitroprusside dose administered within the first 48 hours of infusion was 0.3 μg/kg/min (IQR, 0.2-0.5 μg/kg/min). Median duration of sodium nitroprusside infusion was 5 days (IQR, 4-8 days).

Results of the study showed that 66% of participants experienced a reduction in NT-proBNP values of 25% or higher within 48 hours of treatment onset, regardless of their initial systolic blood pressure. The only independent predictor of treatment efficacy was left ventricular end-diastolic diameter.

Those participants who attained the primary endpoint (“responders”) experienced a significantly lower LOS (median, 15 days [IQR, 10-27 days] vs 19 days [IQR, 12-35 days]; P =.033), as well as a significantly lower incidence of all-cause mortality and rehospitalization for HF at 1 month and 5 months, compared with the “nonresponders” (P <.050). Severe hypotension was reported in 5% of the participants, without any adverse clinical outcomes.

Some key limitations of the study include that it is a retrospective, observational study without a control group. Additionally, limitations associated with the use of a surrogate endpoint (changes in NT-proBNP changes) in the area of acute HF are well known, with many randomized clinical trials not reporting a relationship between a decrease in natriuretic peptides and long-term mortality.

“When added to standard treatment regimen of hospitalized patients with [acute] HF, [sodium nitroprusside] is safe and effective in achieving rapid decongestion and hemodynamic improvement,” the study authors wrote.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 

Reference

Garatti L, Frea S, Bocchino PP, et al. Sodium nitroprusside in acute heart failure: a multicenter historic cohort study. Int J Cardiol. Published online August 6, 2022.
doi:10.1016/j.ijcard.2022.08.009