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Chen TJ, Ho MP. Sympathetic crashing acute pulmonary edema: Role of nitroglycerin infusion. Am J Emerg Med 2023:S0735-6757(23)00356-X. [PMID: 37451967 DOI: 10.1016/j.ajem.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Affiliation(s)
- Tai-Jung Chen
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Min-Po Ho
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
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Mohammed IOH, Swed S, Ezzdean W, Almoshantaf MB, Shebli B, Sawaf B, Hamoda AMA. Sympathetic crashing acute pulmonary edema following pacemaker insertion. Clin Case Rep 2023; 11:e7518. [PMID: 37305863 PMCID: PMC10256871 DOI: 10.1002/ccr3.7518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 03/20/2023] [Accepted: 05/28/2023] [Indexed: 06/13/2023] Open
Abstract
Key Clinical Message Sympathetic crashing acute pulmonary edema (SCAPE) complicating pacemaker implantation is a very uncommon and dangerous occurrence. Following pacemaker implantation, patients need stringent monitoring, and compelling evidence about SCAPE treatment is required. Abstract Sympathetic crashing acute pulmonary edema complicating a pacemaker insertion as the case in our patient is extremely rare. We report a case of 75-year-old man with a complete AV block, which requires urgent pacemaker implantation. Half an hour following the insertion of the pacemaker, an abrupt SCAPE emerged and the patient was incubated immediately.
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Affiliation(s)
| | - Sarya Swed
- Faculty of MedicineAleppo UniversityAleppoSyria
| | - Weaam Ezzdean
- Department of UrologyIbn Al‐Nafees HospitalDamascusSyria
| | | | - Baraa Shebli
- Cardiology Resident, Department of CardiologyAleppo University Hospital, University of AleppoAleppoSyria
| | - Bisher Sawaf
- Department of Internal MedicineHamad Medical CorporationDohaQatar
| | - Abutalib Mohamed Ahmed Hamoda
- Internal Medicine and Interventional Cardiologist and Fellowship ElectrophysiologyUniversity of Alemam AlmahadiKostiSudan
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El Hussein MT, Dolynny A. Hypertensive Emergencies: Common Presentations and Pharmacological Interventions. Crit Care Nurs Q 2023; 46:145-156. [PMID: 36823741 DOI: 10.1097/cnq.0000000000000447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Depending on end-organ involvement, hypertensive crisis is classified as hypertensive urgency or hypertensive emergency. The recognition of a hypertensive crisis will lead to the adequate reduction of blood pressure to ameliorate the incidence of end-organ damage. Hypertensive crises result from dysfunction in the renin-angiotensin-aldosterone system and damage to the vascular bed. They occur commonly in the emergency department setting and can lead to increased mortality rates if not treated. Registered nurses play a vital role in assessing patients and administering medications during hypertensive crises. This article will outline the assessment strategies that registered nurses should implement in critical care units while patients are receiving antihypertensive drugs. We will also underscore the significance of monitoring specific laboratory values to mitigate the potential side effects of these drugs and exclude them when contraindicated.
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Affiliation(s)
- Mohamed Toufic El Hussein
- School of Nursing and Midwifery, Faculty of Health, Community & Education, Mount Royal University, Calgary, Alberta, Canada (Dr El Hussein); Acute Care Nurse Practitioner Medical Cardiology, Coronary Care Unit, Rockyview General Hospital, Calgary, Alberta, Canada (Dr El Hussein); and Mount Royal University, Calgary, Alberta, Canada (Ms Dolynny)
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Hsu CC, Ho MP. High-dose nitroglycerin infusion for acute pulmonary edema. Am J Emerg Med 2023; 67:178. [PMID: 36964111 DOI: 10.1016/j.ajem.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 03/18/2023] [Indexed: 03/26/2023] Open
Affiliation(s)
- Chia-Chun Hsu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Min-Po Ho
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
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Mohammed Abdulsalam T, Hasanin AH, Hussein Mohamed R, Khairy E, Mahmoud D, Habib EK, Badawy AES. A comparative study between angiotensin receptor neprilysin inhibitor (thiorphan/irbesartan) with each of nitrate and carvedilol in a rat model of myocardial ischemic reperfusion injury. Fundam Clin Pharmacol 2023. [PMID: 36868872 DOI: 10.1111/fcp.12886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/02/2023] [Accepted: 02/22/2023] [Indexed: 03/05/2023]
Abstract
The combined angiotensin receptor neprilysin inhibitor is a promising cardioprotective pharmacological agent. This study investigated the beneficial effects of thiorphan (TH)/irbesartan (IRB), in myocardial ischemia-reperfusion (IR) injury, compared to each of nitroglycerin and carvedilol. Male Wistar rats were divided into five groups (10 rats/group): Sham, untreated I/R, TH/IRB + IR (0.1/10 mg/kg), nitroglycerin + IR (0.2 mg/kg), and carvedilol + IR (10 mg/kg). Mean arterial blood pressure, cardiac functions and arrhythmia incidence, duration and score were assessed. Cardiac levels of creatine kinase-MB (CK-MB), oxidative stress, endothelin-1, ATP, Na+ /K+ ATPase pump activity and mitochondria complexes activities were measured. Histopathological examination, Bcl/Bax immunohistochemistry studies and electron microscopy examination of left ventricle were performed. TH/IRB preserved the cardiac functions and mitochondrial complexes activities, mitigated cardiac damage, reduced oxidative stress and arrhythmia severity, improved the histopathological changes and decreased cardiac apoptosis. TH/IRB showed a comparable effect to each of nitroglycerin and carvedilol in alleviating the IR injury consequences. TH/IRB showed significant preservation of mitochondrial complexes activity I and II compared to nitroglycerin. TH/IRB significantly increased LVdP/dtmax and decreased oxidative stress, cardiac damage and endothelin-1 along with increasing the ATP content, Na+ /K+ ATPase pump activity and mitochondrial complexes activity when compared to carvedilol. TH/IRB showed a cardioprotective effect in reducing IR injury that is comparable to each of nitroglycerin and carvedilol that could be explained in part by its ability to preserve mitochondrial function, increase ATP, decrease oxidative stress as well as endothelin 1.
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Affiliation(s)
| | - Amany H Hasanin
- Department of Clinical Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Reham Hussein Mohamed
- Department of Clinical Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eman Khairy
- Department of Medical Biochemistry & Molecular Biology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Dalia Mahmoud
- Department of Medical Biochemistry & Molecular Biology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eman K Habib
- Department of Anatomy and Embryology, Faculty of Medicine, Galala University, Al Galala, Egypt
| | - Ahmed El Sayed Badawy
- Department of Clinical Pharmacology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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6
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Kelly GS, Branstetter LA, Moran TP, Hanzelka N, Cooper CD. Low- versus high-dose nitroglycerin infusion in the management of acute pulmonary edema. Am J Emerg Med 2023; 65:71-75. [PMID: 36587564 DOI: 10.1016/j.ajem.2022.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/15/2022] [Accepted: 12/18/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Nitroglycerin (NTG) is commonly used for the management of pulmonary edema in acute heart failure presentations. Although commonly initiated at low infusion rates, higher infusion rates have favorable pharmacodynamic properties and may improve outcomes in the management of acute pulmonary edema. OBJECTIVES To characterize the clinical outcomes including the time to resolution of severe hypertension when using an initial low dose (<100 μg/min) versus high-dose (≥100 μg/min) strategy. METHODS This was a retrospective study performed at a single, tertiary academic emergency department in Atlanta, GA. We describe the blood pressure effects and key safety outcomes (intubation, hypotension, intensive care unit admissions) during the first hour of treatment of acute pulmonary edema. RESULTS 41 patients were included in the final sample. 27 (66%) received low dose NTG and 14 (34%) received high dose NTG. The high dose group reached their blood pressure faster on average (hazard ratio = 3.5, 95% CI: 1.2-10.1). 8/14 (57%) of patients in the high dose group reached their BP target within the first hour of treatment, compared to 6/27 (22%) in the low dose group. Observed incidence of safety outcomes were similar between the two groups. CONCLUSIONS Higher initial NTG doses may be an effective way to decrease times to achieve blood pressure targets and should be the focus of future trials.
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Affiliation(s)
- Geoffrey S Kelly
- Emory University School of Medicine, Department of Emergency Medicine, 550 W Peachtree St NW, Atlanta, GA 30308, United States of America..
| | - Lindsey A Branstetter
- Emory University, Emergency Medicine Clinical Pharmacy Specialist, Department of Pharmacy, 550 W Peachtree St NW, Atlanta, GA 30308, United States of America
| | - Tim P Moran
- Emory University School of Medicine, Department of Emergency Medicine, 550 W Peachtree St NW, Atlanta, GA 30308, United States of America
| | - Nathan Hanzelka
- University of Georgia College of Pharmacy, 550 W Peachtree St NW, Atlanta, GA 30308, United States of America
| | - Claudia D Cooper
- Emory University, Emergency Medicine Clinical Pharmacy Specialist, Department of Pharmacy, 550 W Peachtree St NW, Atlanta, GA 30308, United States of America
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Siddiqua N, Bhaskararayuni J, Sahu AK, Kumar A, Nayer J. Taming the Tiger: Ultra high dose nitroglycerin in managing sympathetic crashing acute pulmonary edema patient. Am J Emerg Med 2023; 67:194.e1-194.e5. [PMID: 37002114 DOI: 10.1016/j.ajem.2023.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
INTRODUCTION Sympathetic Crashing Acute Pulmonary Edema (SCAPE) lies on the end of the acute heart failure syndrome spectrum with pulmonary edema in all lung zones. NTG at lower doses (10-20 μg/min) cause preload reduction, and at higher doses (> 100 μg/min) causes after-load reduction by arterial dilatation. The main aim is to decrease the afterload at the earliest to cut the vicious cycle caused by sudden sympathetic upsurge. To our knowledge, this is the highest nitroglycerin dose usage in the literature. CASE A 60-year-old male with no known prior co-morbidities presented to our Emergency with complaints of acute onset severe shortness of breath, which was also associated with extreme diaphoresis, agitation, anxiety, and palpitations. On Examination, the patient was hypoxic and hypertensive with severe tachypnea and tachycardia. On Auscultation, diffuse bilateral crackles in all areas were heard. Point of care ultrasound showed bilateral B-profile in all lung zones, inferior vena cava was >50% collapsible. We managed the patient with non-invasive ventilation and ultrahigh dose nitroglycerin/ highest ever- 9 mg intravenous bolus with 76 mg infusion. The patient had improved within hours and did not require oxygen. The patient was discharged from the emergency after a few hours of observation. DISCUSSION SCAPE occurs due to a vicious spiral involving increasing sympathetic outflow, excessive afterload, and worsening heart failure. The central, defining pathophysiological feature of SCAPE is pathologically elevated afterload due to systemic vasoconstriction and hypertension. SCAPE patients may be euvolemic, hypovolemic or hypervolemic. The problem is shift of fluid into the lungs rather than hypervolemia. The emphasis on treating pulmonary edema has shifted from diuretics to vasodilators, especially high-dose nitrates, combined with non-invasive positive pressure ventilation. CONCLUSION This is the first report describing the safe and effective administration of ultra-high dose bolus/ highest dose ever and prolonged high-dose infusion for SCAPE, along with Non-invasive ventilation, which has prevented mechanical ventilation and mortality. High doses of intravenous NTG are extremely effective and safe for SCAPE patients.
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Houseman BS, Martinelli AN, Oliver WD, Devabhakthuni S, Mattu A. High-dose nitroglycerin infusion description of safety and efficacy in sympathetic crashing acute pulmonary edema: The HI-DOSE SCAPE study. Am J Emerg Med 2023; 63:74-78. [PMID: 36327753 DOI: 10.1016/j.ajem.2022.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 10/07/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Sympathetic crashing acute pulmonary edema (SCAPE) is a medical emergency in which severe, acute elevation in blood pressure results in acute heart failure and fluid accumulation in the lungs. Without prompt recognition and treatment, the condition often progresses rapidly to respiratory failure necessitating intubation and intensive care unit (ICU) admission. In addition to non-invasive positive pressure ventilation (NIPPV), high-dose nitroglycerin (HDN) has become a mainstay of treatment; however, an optimal dosing strategy has not been established. OBJECTIVE The purpose of this study was to describe the characteristics and outcomes of patients who received an HDN infusion (≥ 100 μg/min) for the management of SCAPE in the Emergency Department (ED) of a large urban academic medical center. Outcomes were also analyzed to determine predictors of safety and efficacy including use of adjunct medication therapies. RESULTS There were 67 adult patients who received HDN infusion for SCAPE from January 1, 2018 to December 31, 2018. The median (IQR) systolic blood pressure (SBP) on initiation of HDN infusion was 211 (192-233) mmHg. Patients were 63% male, 84% black, 51% had a history of heart failure (HF), and 36% had end-stage renal disease (ESRD). IV nitroglycerin (NTG) was initiated at a median (IQR) dose of 100 (100-200) mcg/min with median (IQR) peak rate in the first hour of 200 (127.5-200) mcg/min and an absolute maximum observed rate of 400 μg/min overall. 73% of patients received NIPPV, 48% sublingual (SL) or IV bolus nitroglycerin before HDN infusion, 58% loop diuretic, and 34% angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB). Rates of ICU admission, intubation, acute kidney injury (AKI) at 48 h, and hypotension were 37%, 21%, 13%, and 4% respectively. CONCLUSION This is the largest to date study describing the use of an HDN infusion (≥100 μg/min) strategy for the management of SCAPE. HDN infusion may be a safe alternative strategy to intermittent bolus HDN.
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Affiliation(s)
- Brandon S Houseman
- Department of Pharmacy, The University of Maryland Medical Center, Baltimore, MD, United States of America
| | - Ashley N Martinelli
- Department of Pharmacy, The University of Maryland Medical Center, Baltimore, MD, United States of America.
| | - Wesley D Oliver
- Department of Pharmacy, The University of Maryland Medical Center, Baltimore, MD, United States of America
| | - Sandeep Devabhakthuni
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, United States of America
| | - Amal Mattu
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
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Twiner MJ, Hennessy J, Wein R, Levy PD. Nitroglycerin Use in the Emergency Department: Current Perspectives. Open Access Emerg Med 2022; 14:327-333. [PMID: 35847764 PMCID: PMC9278720 DOI: 10.2147/oaem.s340513] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022] Open
Abstract
Nitroglycerin, a fast-acting vasodilator, is commonly used as a first-line agent for angina in the emergency department and to manage chest pain due to acute coronary syndromes. It is also a treatment option for other disease states such as acute heart failure, pulmonary edema, and aortic dissection. Nitroglycerin is converted to nitric oxide, a potent vasodilator, in the body, leading to venodilation at lower dosages and arteriodilation at higher dosages that results in both preload and afterload reduction, respectively. Although nitroglycerin has historically been administered as a sublingual tablet and/or spray, it is often given intravenously in the emergency department as this enables titration to effect with predictable pharmacokinetics. In this review article, we outline the indications, mechanism of action, contraindications, and adverse effects of nitroglycerin as well as review relevant literature and make general recommendations regarding the use of nitroglycerin in the emergency department.
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Affiliation(s)
- Michael J Twiner
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.,Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
| | - John Hennessy
- College of Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Rachel Wein
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI, USA.,Integrative Biosciences Center, Wayne State University, Detroit, MI, USA
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Eitta M, Abdelmoneum M, Elrabat K, Bendary A. Bolus versus continuous infusion of nitroglycerin for the treatment of acute hypertensive heart failure. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2022. [DOI: 10.4103/ijca.ijca_48_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Mathew R, Kumar A, Sahu A, Wali S, Aggarwal P. High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study. J Emerg Med 2021; 61:271-277. [PMID: 34215472 DOI: 10.1016/j.jemermed.2021.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/19/2021] [Accepted: 05/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sympathetic crashing acute pulmonary edema (SCAPE) is a severe form of hypertensive acute heart failure with a dramatic presentation. Rapid identification and management in the emergency department (ED) is key to saving these patients and preventing morbidity associated with endotracheal intubation and intensive care treatment. Use of high-dose nitroglycerin (NTG) and noninvasive ventilation (NIV) has been advocated in management of such patients. OBJECTIVE To study the feasibility and safety of high-dose NTG combined with NIV in SCAPE. METHODS This was a prospective observational pilot study done in the ED of a tertiary care hospital. All patients were treated with high-dose NTG and NIV. The primary objective was to study the feasibility and safety of the SCAPE management protocol in terms of the outcome of the patient. Resolution of symptoms in 6 h and need for intubation were recorded as endpoints. Any complications associated with high-dose NTG were also recorded. RESULTS A total of 25 patients were recruited. The mean bolus dose of NTG given was 872 μg, and mean cumulative dose, 35 mg. There was no incidence of hypotension after the bolus dose of nitroglycerin. Eleven patients had resolution of symptoms at 3 h of therapy. Twenty-four patients were discharged from the ED itself after a brief period of observation, and one patient was intubated and shifted to the intensive care unit. CONCLUSION Use of our specific SCAPE treatment algorithm, which included high-dose NTG and NIV, was safe and provided rapid resolution of symptoms.
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Affiliation(s)
- Roshan Mathew
- Department of Emergency Medicine, All India Institute of Medical Science (AIIMS), New Delhi, India
| | - Akshay Kumar
- Department of Emergency Medicine, All India Institute of Medical Science (AIIMS), New Delhi, India.
| | - Ankit Sahu
- Department of Emergency Medicine, All India Institute of Medical Science (AIIMS), New Delhi, India
| | - Sachin Wali
- Department of Emergency Medicine, All India Institute of Medical Science (AIIMS), New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Science (AIIMS), New Delhi, India
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Gyory M, Abdallah S, Lagina A, Levy PD, Twiner MJ. Ultra-high dose intravenous nitroglycerin in an ESRD patient with acutely decompensated heart failure. J Am Coll Emerg Physicians Open 2021; 2:e12387. [PMID: 33718922 PMCID: PMC7926001 DOI: 10.1002/emp2.12387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022] Open
Abstract
Acute cardiogenic pulmonary edema is a highly unstable and potentially lethal condition that is most commonly associated with markedly elevated blood pressure (BP). Use of nitrates, diuretics, and non-invasive positive pressure ventilatory support are the mainstays of early intervention and stabilization. Use of high-dose bolus intravenous nitroglycerin, which causes both preload and afterload reduction, has shown significant promise in studies to date, reducing the need for endotracheal intubation (ETI) and intensive care unit admission. To date, the highest recorded total dose of nitroglycerin used during the initial stabilization of acute pulmonary edema has been 20 mg. Here, we describe a patient with end-stage renal disease who developed acute cardiogenic pulmonary edema and received a total of 59 mg nitroglycerin (56 mg push dose intravenous + 3 mg intravenous drip) over 41 minutes leading to successful stabilization and avoidance of ETI, facilitating rapid initiation of emergent hemodialysis.
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Affiliation(s)
- Michael Gyory
- Detroit Receiving HospitalWayne State UniversityDetroitMichiganUSA
| | | | - Anthony Lagina
- Department of Emergency MedicineIntegrative Biosciences CenterWayne State UniversityDetroitMichiganUSA
| | - Phillip D. Levy
- Department of Emergency MedicineIntegrative Biosciences CenterWayne State UniversityDetroitMichiganUSA
| | - Michael J. Twiner
- Department of Emergency MedicineIntegrative Biosciences CenterWayne State UniversityDetroitMichiganUSA
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Harrison N, Pang P, Collins S, Levy P. Blood Pressure Reduction in Hypertensive Acute Heart Failure. Curr Hypertens Rep 2021; 23:11. [PMID: 33611627 DOI: 10.1007/s11906-021-01127-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW To review the key clinical and research questions regarding blood pressure (BP) reduction with vasodilators in the early management of hypertensive acute heart failure (H-AHF). RECENT FINDINGS Despite numerous AHF vasodilator clinical trials in the past two decades, virtually none has studied a population where vasoconstriction is the predominant physiology, and with the agents and doses most commonly used in contemporary practice. AHF patients are remarkably heterogenous by vascular tone, and this heterogeneity is not always discernible through BP or clinical exam. Emerging data suggest that diastolic BP may be a stronger correlate of vascular tone in AHF than systolic BP, despite the latter historically serving as a key inclusion criterion for vasodilator clinical trials. Existing data are limited. A clinical trial that evaluates vasodilators in a manner of use consistent with contemporary practice, specifically within the subpopulation of patients with true H-AHF, is greatly needed. Until then, observational data supports long-standing vasodilators such as nitroglycerin, administered by IV bolus, and with goal reduction of SBP ≤25% as a safe first-line approach for patients with severe H-AHF presentations.
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Affiliation(s)
| | - Peter Pang
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sean Collins
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Phillip Levy
- Wayne State University School of Medicine, Detroit, MI, USA
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14
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Raggi JR, O'Connell TW, Singer DJ. Nicardipine: When high dose nitrates fail in treating heart failure. Am J Emerg Med 2020; 45:681.e3-681.e5. [PMID: 33358327 DOI: 10.1016/j.ajem.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022] Open
Abstract
Sympathetic Crashing Acute Pulmonary Edema (SCAPE) describes patients who present with acute hypertensive cardiogenic pulmonary edema. These patients present in respiratory distress, and requiring immediate medical and airway management. The treatment of SCAPE includes non-invasive positive pressure ventilation (NIPPV) to maintain oxygenation, and high dose nitrates to lower blood pressure and reduce afterload. We present a case report of a patient with refractory hypertension to high dose nitrates likely due to nitroglycerin resistance or an attenuated response. The addition of nicardipine led to marked clinical improvement, normalized blood pressure and spared the patient from endotracheal intubation and admission to the intensive care unit.
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Affiliation(s)
- Jason R Raggi
- Lincoln Hospital, Bronx, NY, United States of America.
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Prehospital Treatment of Acute Pulmonary Edema with Intravenous Bolus and Infusion Nitroglycerin. Prehosp Disaster Med 2020; 35:663-668. [PMID: 33023684 DOI: 10.1017/s1049023x20001193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The study describes the implementation of a prehospital treatment algorithm that included intravenous (IV) bolus (IVB) nitroglycerin (NTG) followed by maintenance infusion for the treatment of acute pulmonary edema (APE) in a single, high-volume Emergency Medical Services (EMS) system. METHODS This is a retrospective chart review of patients who received IVB NTG for APE in a large EMS system in Minnesota and Wisconsin (USA). Inclusion criteria for treatment included a diagnosis of APE, systolic blood pressure ≥120mmHg, and oxygen saturation (SpO2) ≤93% following 800mcg of sublingual NTG. Patients received a 400mcg IVB of NTG, repeated every two minutes as needed, and subsequent infusion at 80mcg/min for transport times ≥10 minutes. RESULTS Forty-four patients were treated with IVB NTG. The median total bolus dose was 400mcg. Twenty patients were treated with NTG infusion following IVB NTG. The median infusion rate was 80mcg/min. For all patients, the initial median blood pressure was 191/113mmHg. Five minutes following IVB NTG, it was 160/94mmHg, and on arrival to the emergency department (ED) it was 152/90mmHg. Five minutes after the initial dose of IVB NTG, median SpO2 increased to 92% from an initial reading of 88% and was 94% at hospital arrival. One episode of transient hypotension occurred during EMS transport. CONCLUSION Patients treated with IVB NTG for APE had reduction in blood pressure and improvement in SpO2 compared to their original presentation. Prehospital treatment of APE with IVB appears to be feasible and safe. A randomized trial is needed to confirm these findings.
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Strauss M, Leischik R, Jehn U, Padberg JS, Pistulli R, Kümpers P, Reinecke H. [The hypertensive emergency situation : Recommendations for initial drug therapy management]. Med Klin Intensivmed Notfmed 2020; 117:41-48. [PMID: 32940723 DOI: 10.1007/s00063-020-00728-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The hypertensive emergency situation is characterized by an acute-mostly life-threatening-blood pressure derailment with the risk of acute end organ damage. It is an acute manifestation of arterial hypertension, which manifests in a variety of symptoms. The etiology is in most cases long-term (chronic) hypertension as a result of low compliance or inadequate antihypertensive therapy. It can also occur as a first manifestation of arterial hypertension. It requires timely antihypertensive drug therapy, which should be initiated in an intensive or intermediate care unit. The choice of antihypertensive therapy regimen should be based on the underlying end organ damage. Fast-acting, easily controllable and intravenously administered substances should be preferred. The most commonly used substances (groups) are urapidil, nitroglycerin, beta blockers and short-acting calcium channel blockers. With a few exceptions, a deliberate, rapid reduction in blood pressure of no more than 20-25% of the initial value is sufficient for extracerebral causes. A subsequent systolic blood pressure target of 160/100 mm Hg should be aimed for within the next 2-6 h. An overly rapid drop in blood pressure can lead to reduced blood flow to the central nervous system due to changes in autoregulation. Exceptions to this rule are acute aortic dissection and flash pulmonary edema-in these cases, prompt blood pressure normalization should be achieved. The initial acute therapy should be followed by a more detailed investigation of the cause and a long-term therapy setting based on this.
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Affiliation(s)
- M Strauss
- Klinik für Kardiologie I: Koronare Herzerkrankung, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland. .,Klinik für Kardiologie, Lehrbereich Prävention und Gesundheitsförderung, Fakultät für Gesundheit, Universität Witten/Herdecke, Hagen, Deutschland.
| | - R Leischik
- Klinik für Kardiologie, Lehrbereich Prävention und Gesundheitsförderung, Fakultät für Gesundheit, Universität Witten/Herdecke, Hagen, Deutschland
| | - U Jehn
- Medizinische Klinik D, Allgemeine Innere Medizin und Notaufnahme sowie Nieren- und Hochdruckkrankheiten und Rheumatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - J-S Padberg
- Klinik für Kardiologie I: Koronare Herzerkrankung, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - R Pistulli
- Klinik für Kardiologie I: Koronare Herzerkrankung, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - P Kümpers
- Medizinische Klinik D, Allgemeine Innere Medizin und Notaufnahme sowie Nieren- und Hochdruckkrankheiten und Rheumatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - H Reinecke
- Klinik für Kardiologie I: Koronare Herzerkrankung, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
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Hodroge SS, Glenn M, Breyre A, Lee B, Aldridge NR, Sporer KA, Koenig KL, Gausche-Hill M, Salvucci AA, Rudnick EM, Brown JF, Gilbert GH. Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2020; 21:849-857. [PMID: 32726255 PMCID: PMC7390576 DOI: 10.5811/westjem.2020.2.43896] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 02/21/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California. METHODS We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations. RESULTS PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol. CONCLUSION Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.
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Affiliation(s)
- Sammy S Hodroge
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Melody Glenn
- University of Arizona, Department of Emergency Medicine, Tucson, Arizona
| | - Amelia Breyre
- Alameda Health System, Highland Hospital, Department of Emergency Medicine, Oakland, California
| | - Bennett Lee
- Hawaii Emergency Physicians Associated, Kailua, Hawaii
| | - Nick R Aldridge
- Kaiser Permanente San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kristi L Koenig
- County of San Diego Health & Human Services Agency, EMS, University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Marianne Gausche-Hill
- Harbor-UCLA Medical Center, Department of Emergency Medicine, Los Angeles County EMS Agency, Santa Fe Springs, California
| | | | | | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- Stanford University, Department of Emergency Medicine, Palo Alto, California
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Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med 2020; 44:262-266. [PMID: 32278569 DOI: 10.1016/j.ajem.2020.03.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/27/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022] Open
Abstract
Sympathetic crashing acute pulmonary edema (SCAPE) describes the most severe presentation of acute heart failure (AHF). Immediate intervention is required to prevent hemodynamic decompensation and endotracheal intubation. Although high-dose nitroglycerin (>100 μg/min) has been described for this clinical scenario in limited case reports, the concern for adverse effects such as hypotension and syncope limit providers comfortability in initiating nitroglycerin at these doses. Described here is a case series of four patients who safely and effectively received high-dose nitroglycerin infusions for the management of SCAPE.
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Affiliation(s)
- Krisi Stemple
- Department of Pharmacy, The University of Vermont Medical Center, United States of America.
| | - Kyle M DeWitt
- Department of Pharmacy, The University of Vermont Medical Center, United States of America
| | - Blake A Porter
- Department of Pharmacy, The University of Vermont Medical Center, United States of America
| | - Michael Sheeser
- Department of Surgery, Division of Emergency Medicine, The University of Vermont Medical Center, United States of America
| | - Eike Blohm
- Department of Surgery, Division of Emergency Medicine, The University of Vermont Medical Center, United States of America
| | - Mark Bisanzo
- Department of Surgery, Division of Emergency Medicine, The University of Vermont Medical Center, United States of America
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Patrick C, Ward B, Anderson J, Rogers Keene K, Adams E, Cash RE, Panchal AR, Dickson R. Feasibility, Effectiveness and Safety of Prehospital Intravenous Bolus Dose Nitroglycerin in Patients with Acute Pulmonary Edema. PREHOSP EMERG CARE 2020; 24:844-850. [DOI: 10.1080/10903127.2020.1711834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Wang K, Samai K. Role of high-dose intravenous nitrates in hypertensive acute heart failure. Am J Emerg Med 2020; 38:132-137. [DOI: 10.1016/j.ajem.2019.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 12/20/2022] Open
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Abstract
PURPOSE OF REVIEW Acute heart failure (AHF) is a common emergency presentation in Sub-Saharan Africa (SSA). In the current review, we present the most recent data on the epidemiology of AHF in SSA and discuss recommended approaches to management in resource-limited settings, with a particular focus on primary and secondary facilities (e.g., health centers and district hospitals), where these patients often present. RECENT FINDINGS AHF in SSA is most often due to hypertension, cardiomyopathies, and rheumatic heart disease. The etiology of AHF may be different in rural as compared with urban settings. Diagnostic tools for AHF are often lacking in SSA, especially at the first-level facilities. Point-of-care ultrasound (POCUS) and biomarker tests, such as brain natriuretic peptide (BNP), offer promise in helping to mitigate diagnostic challenges. POCUS can also help distinguish among types of heart failure and prompt the correct treatment strategy. Many of the drugs and equipment commonly used to treat AHF in resource-rich settings are lacking in SSA. However, some adaptations of commonly available materials may provide temporary alternatives. The epidemiology of AHF in SSA differs from that of high-income settings. Management of AHF at the first-level facility in SSA is an important and understudied problem. Simplified diagnostic and treatment algorithms rooted in knowledge of the local epidemiology should be developed and tested as part of broader efforts to combat cardiovascular disease in SSA.
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Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med 2018; 55:635-646. [DOI: 10.1016/j.jemermed.2018.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/09/2018] [Accepted: 08/03/2018] [Indexed: 12/21/2022]
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24
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Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med 2018; 36:1526.e5-1526.e7. [DOI: 10.1016/j.ajem.2018.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 12/25/2022] Open
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Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med 2018; 18:34-36. [PMID: 29942881 PMCID: PMC6009803 DOI: 10.1016/j.tjem.2018.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 11/13/2022] Open
Abstract
Acute pulmonary edema due to sympathetic surge and increased peripheral vascular resistance often present to the emergency department (ED) with markedly elevated blood pressure, severe dyspnea, and desaturation. This condition is known as “SCAPE” (sympathetic crashing acute pulmonary edema). We present three SCAPE patients who were successfully treated with high-dose nitroglycerin (NTG) and bilevel positive airway pressure (BiPAP) ventilation. All three patients presented with respiratory failure on arrival but rapidly improved after treatment and did not require endotracheal intubation or admission to the intensive care unit (ICU). SCAPE patients usually present to the ED with extreme respiratory distress associated with diaphoresis, restlessness, and high blood pressure. Emergency physicians must know how to manage SCAPE with high-dose nitrates and NIPPV (noninvasive positive pressure ventilation) because, when treated promptly, one will not only save a life but also obviate the need for endotracheal intubation and ICU admission.
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Affiliation(s)
- Yi-Ting Hsieh
- Emergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei City, Taiwan
| | - Tai-Ying Lee
- Emergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei City, Taiwan
| | - Jui-Shih Kao
- Emergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei City, Taiwan
| | - Hsin-Lin Hsu
- Emergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei City, Taiwan
| | - Chee-Fah Chong
- Emergency Department, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei City, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
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26
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Long B, Koyfman A, Chin EJ. Misconceptions in acute heart failure diagnosis and Management in the Emergency Department. Am J Emerg Med 2018; 36:1666-1673. [PMID: 29887195 DOI: 10.1016/j.ajem.2018.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes. OBJECTIVE This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls. DISCUSSION AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up. CONCLUSION A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States
| | - Eric J Chin
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
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Abstract
PURPOSE OF REVIEW In spite of advances in our understanding of acute heart failure (AHF) and its different phenotypic expressions, AHF management is still centered on volume removal with intravenous diuretics. This narrative review describes the pathophysiology underlying hypertensive AHF and appraises therapies targeting these mechanisms. RECENT FINDINGS Vascular redistribution rather than volume overload may be the primary determinant of elevated cardiac filling pressures and subsequent pulmonary congestion in patients with hypertensive AHF; in these patients, vasodilators should be the predominant treatment. Additional therapy with diuretics in hypertensive AHF should be relegated to the treatment of overt volume overload or persistent congestion in spite of optimized hemodynamics. Intravenous nitroglycerin at high doses can rapidly achieve pulmonary decongestion and reduce downstream critical care needs in these patients. The therapeutic role for synthetic peptides with vasodilator properties has yet to be defined. Evidence supporting both old and new vasodilator therapies is limited by a paucity of well-designed studies and failure to demonstrate improvement in long-term outcomes. Targeted study of this phenotype of AHF is needed before vasodilator therapies become incorporated into treatment guidelines.
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Collins SP, Levy PD, Fermann GJ, Givertz MM, Martindale JM, Pang PS, Storrow AB, Diercks DD, Michael Felker G, Fonarow GC, Lanfear DJ, Lenihan DJ, Lindenfeld JM, Frank Peacock W, Sawyer DM, Teerlink JR, Butler J. What's Next for Acute Heart Failure Research? Acad Emerg Med 2018; 25:85-93. [PMID: 28990334 DOI: 10.1111/acem.13331] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/29/2017] [Accepted: 10/01/2017] [Indexed: 12/11/2022]
Abstract
Each year over one million patients with acute heart failure (AHF) present to a United States emergency department (ED). The vast majority are hospitalized for further management. The length of stay and high postdischarge event rate in this cohort have changed little over the past decade. Therapeutic trials have failed to yield substantive improvement in postdischarge outcomes; subsequently, AHF care has changed little in the past 40 years. Prior research studies have been fragmented as either "inpatient" or "ED-based." Recognizing the challenges in identification and enrollment of ED patients with AHF, and the lack of robust evidence to guide management, an AHF clinical trials network was developed. This network has demonstrated, through organized collaboration between cardiology and emergency medicine, that many of the hurdles in AHF research can be overcome. The development of a network that supports the collaboration of acute care and HF researchers, combined with the availability of federally funded infrastructure, will facilitate more efficient conduct of both explanatory and pragmatic trials in AHF. Yet many important questions remain, and in this document our group of emergency medicine and cardiology investigators have identified four high-priority research areas.
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Affiliation(s)
- Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
| | - Phillip D. Levy
- Department of Emergency Medicine Wayne State University Detroit MI
| | - Gregory J. Fermann
- Department of Emergency Medicine University of Cincinnati Medical Center Cincinnati OH
| | | | | | - Peter S. Pang
- Department of Emergency Medicine Indiana University School of Medicine & Indianapolis EMS Indianapolis IN
| | - Alan B. Storrow
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
| | - Deborah D. Diercks
- Department of Emergency Medicine University of Texas Southwestern Medical Center Dallas TX
| | | | - Gregg C. Fonarow
- Division of Cardiology University of California Los Angeles Ronald Reagan Medical Center Los AngelesCA
| | | | - Daniel J. Lenihan
- Division of Cardiology Vanderbilt University Medical Center Nashville TN
| | | | - W. Frank Peacock
- Department of Emergency Medicine Baylor University Medical Center Houston TX
| | | | - John R. Teerlink
- Division of Cardiology University of California San Francisco and the San Francisco VA San Francisco CA
| | - Javed Butler
- Division of Cardiology Stony Brook University Medical Center Stony BrookNY
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The Use of Nitrates in the Management of Acute Heart Failure in the Emergency Department: a Review. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0132-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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