Popular bias about nesiritide

Remember the brouhaha almost two years ago about the JAMA meta-analysis on 30 day mortality with the use of nesiritide? The increased mortality observed with nesiritide was not statistically significant, but based on popular reaction you would have thought it was cyanide. So, why the silence about these two recent papers?

In brief, the February 13 issue of JACC contains this report of a randomized double blind trial of nesiritide after coronary artery bypass in patients with left ventricular systolic dysfunction, showing that nesiritide was associated with improved renal function, decreased length of stay and lower 180 day mortality.

This meta-analysis from American Heart Journal (posted on Medscape February 7), arguably methodologically stronger than the aforementioned JAMA meta-analysis, showed no difference in mortality between nesiritide and comparison groups in 7 studies. For an analysis of the strengths and weaknesses of the two meta-analyses read the discussion section of the American Heart Journal paper particularly in reference to the heavier use of inotropes in the neseritide treated patients in the JAMA paper. (It’s well known that inotropes increase mortality in heart failure).

I’m lukewarm on neseritide and there are enough remaining questions about its efficacy and safety to keep it off the front line, at least for now. For acute cardiogenic pulmonary edema I prefer an approach utilizing nitroglycerine, loop diuretics and CPAP or NPPV. (A randomized controlled trial of nesiritide to evaluate for mortality, renal function and cost effectiveness will begin this year).