Frusemide or nitrates for acute heart failure?

Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care

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.

Treatment and Outcome of Acute Cardiogenic Pulmonary Oedema Presenting to an Emergency Department in Hong Kong: Retrospective Cohort Study

Objectives

To explore the epidemiology, treatment and outcome of acute cardiogenic pulmonary oedema (ACPO) in a Hong Kong emergency department (ED).

Methods

This was a retrospective cohort study in a university hospital ED. Cases were identified from ED records and resuscitation room logbooks. The study extended from 1 September 2004 to 30 April 2005. Parametric tests and logistic regression were used to identify predictors of survival.

Results

A total of 140 patients were identified, with a mean age of 75 years and male:female ratio of 1:1.4. Mean values (range) on presentation were as follows: pulse rate 103 beats/minute (36–108); blood pressure (BP) 169/88 mmHg (77-274/20-162) and respiratory rate 31 breaths/minute (12–88). Past medical history included previous ACPO (12.1%), diabetes (45.7%), chronic obstructive pulmonary disease (9.3%), ischaemic heart disease (45.0%), hypertension (72.1%) and congestive heart failure (40.7%). On admission, 47.1% had pH<7.35 and 40.7% had PaCO2>5.5kPa. ED treatments included: sublingual nitrates (n=2), intravenous (IV) nitrates (n=89, median 10 mg/hr), IV frusemide (n=85, median 40 mg), IV morphine (n=25, median 3 mg). There were 21 patients on non-invasive ventilation; 27 intubations and 41 patients were admitted to the intensive care unit. Survival to discharge was 95.7%; and median length of hospital stay was 8 days. The 90-day all-cause hospital readmission rate was 30.0%. The 30-day mortality was 12.9% (n=18) and 90-day mortality was 29.3% (n=41). Logistic regression showed that past history of hypertension (p=0.0061), higher systolic BP on ED discharge (p=0.0102) and lower creatinine following treatment (p=0.035) were predictors of improved survival at 90 days.

Conclusion

ACPO commonly presents to the ED in Hong Kong and has a high 90-day mortality. Previous hypertension, higher systolic blood pressure on leaving the ED and lower creatinine following treatment predict improved survival at 90 days.

Acute Arterial Hypertension in Acute Pulmonary Edema: Mostly a Trigger or an Associated Phenomenon?

BACKGROUND

The role of acute arterial hypertension in acute pulmonary edema (APE) as an associated or triggering phenomenon has been poorly investigated and is relevant to patient management.

METHODS

This was a prospective observational study of clinical, electrocardiographic, and echocardiographic characteristics of patients with APE. Potential triggers, including acute coronary syndrome (ACS), rapid atrial fibrillation (AF) (≥ 120 bpm in AF), fever > 38°C or volume overload, isolated acute hypertension (systolic blood pressure ≥ 170 mm Hg), and unknown factors were investigated.

RESULTS

There were 742 patients, 578 with coronary artery disease (78%), 116 with valvular heart disease or cardiomyopathy (16%), and 47 without identifiable heart disease (6%). ACS was present in 482 (65%) patients (silent in 154 of them), AF was present in 76 (10%) patients, fever/volume overload was present in 62 (8%) patients, acute hypertension was present in 50 (7%) patients, and no apparent trigger was seen in 72 (10%) patients. Admission hypertension occurred in 260 patients (35%): 155 (60%) with ACS (silent in 49 [32%]), 36 (14%) with AF, 19 (7%) with fever/volume overload, and 59 (19%) as an isolated trigger. Similar results were obtained when analyzing patients using coronary angiography (467 patients [63%]). Acute hypertension was present more frequently in patients with severe hypoventilation (arterial Pco₂ > 60 mm Hg) than in those without (57% vs 29%; P < 0.001) and in those without moderate-severe mitral regurgitation than in those with (51% vs 30%; P < 0.001).

CONCLUSIONS

In patients with APE, with or without ACS, acute hypertension is often present but mainly as an associated/reactive phenomenon and seems favoured by severe hypoventilation. Silent myocardial ischemia/necrosis deserves systematic investigation because it is not rare that it may be the underlying cause of APE.

Competition for intrathoracic space reduces lung capacity in patients with chronic heart failure: a radiographic study

BACKGROUND

The purpose of this study was to determine the influence of changes in cardiac size on total lung volume in patients with chronic heart failure compared to control subjects.

METHODS

Forty-four patients and age-, gender-, and height-matched control participants were recruited. All participants underwent posteroanterior and lateral chest radiography for volumetric estimations of the total thoracic cavity (TTC), diaphragm, heart, and lungs. To assess the relationship between chronic heart failure severity and cardiac enlargement, patients with chronic heart failure were classified into groups based on New York Heart Association class, as follows: class I and II, n = 26 (group A); class III and IV, n = 18 (group B).

RESULTS

There was no difference between the groups for TTC volume (TTCV) [p = 0.56]. Cardiac volumes were significantly different between all groups for both the absolute volumes (p < 0.001) were calculated as a percentage of TTCV (p < 0.001), with the largest cardiac volumes in group B (twice the volume of healthy control subjects). When expressed as a percentage of TTCV, there also was a clear reduction in lung volumes as a function of disease severity (p < 0.001).

CONCLUSIONS

The present study demonstrates a close relationship between the severity of heart failure and cardiac size. These changes in cardiac size within a closed thoracic cavity may pose significant constraints on the lungs, resulting in reductions in lung volumes that likely play a major role in the restrictive breathing patterns often reported in patients with chronic heart failure.

Acute perioperative heart failure

PURPOSE OF REVIEW

Changes in epidemiology and advances in the treatment of coronary artery disease, hypertension and diabetes mellitus have increased the prevalence of heart failure in the general population, and also the number of patients with heart failure presenting for surgery. Particularly in the perioperative period, patients with chronic heart failure are faced with numerous triggers of acute decompensation that can partly be avoided or treated. Patients without preexisting myocardial contractile dysfunction may sustain severe perioperative complications, e.g. myocardial infarction, with subsequent acute heart failure as a consequence. Approaches for diagnosis and treatment in these situations may vary considerably.

RECENT FINDINGS

Patients with preexisting heart failure undergoing non-cardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care. The importance of heart failure as an independent risk factor is underlined by the fact that patients with coronary artery disease but without heart failure have a similar 30-day mortality rate to the general population. B-type natriuretic peptide testing is an attractive and non-invasive tool in non-surgical patients for the diagnosis of heart failure, but its role in the perioperative period for the diagnosis of myocardial contractile dysfunction is less clear. For inotropic support, levosimendan, a myofilament calcium sensitizer, has become available in several European countries, and encouraging positive reports have recently been published in this area.

SUMMARY

The role of B-type natriuretic peptide testing in the perioperative period is confounded by several variables that limit its use in that setting. New developments in positive inotropic therapy are challenging older and potentially harmful treatment strategies.

Modern Management of Cardiogenic Pulmonary Edema

Cardiogenic pulmonary edema (CPE) is a life-threatening condition that is frequently encountered in standard emergency medicine practice. Traditionally, diagnosis was based on physical assessment and chest radiography and treatment focused on the use of morphine sulfate and diuretics. Numerous advances in diagnosis and treatment have been made, however. Serum testing for B-type natriuretic peptide (BNP) has improved the accuracy of diagnoses in these patients. Treatment should focus on fluid redistribution with aggressive preload and afterload reduction rather than simply on diuresis. Some specific medications and noninvasive positive pressure ventilation have been shown to be safe and rapidly effective in improving patients' symptoms and improve outcomes.

Treating critical illness: the importance of first doing no harm

Singer and Glynne present evidence to suggest that the short- term benefits of many interventions for treating critical illness may camouflage an underlying tendency to cause harm.

[Medical treatment of acute heart failure]

Medical treatment of acute decompensated heart failure has little changed in the last years, except with the advent of non-invasive ventilation. Doppler-echocardiography and BNP dosing have simplified the diagnostic approach and limited the need for invasion evaluation. Vasodilators remain probably underused whereas some doubts have emergency regarding the safety of positive inotropes. Analysis of the hemodynamic profile is mandatory for an optimal management of these patients. The next decade will be that of morbimortality trials in this common form of heart failure with severe prognosis.

Pharmacological therapy of acute cardiogenic pulmonary oedema in the emergency department

This paper critically reviews the major drug types that are currently used in the management of acute cardiogenic pulmonary oedema. As decompensated heart failure becomes an increasingly common problem in emergency departments in the developed world, optimization of emergency drug therapy for these critically ill patients is essential. The evidence base for 'routine therapy' in the ED is considered. The review also briefly considers emerging pharmacological therapies that may have an impact on future management of cardiogenic pulmonary oedema.

Contralateral medial temporal lobe damage in right but not left temporal lobe epilepsy: a (1)H magnetic resonance spectroscopy study

BACKGROUND

Proton magnetic resonance spectroscopy (MRS) of the hippocampus is useful in lateralising the epileptic focus in temporal lobe epilepsy for subsequent surgical resection. Previous studies have reported abnormal contralateral MRS values in up to 50% of the patients.

OBJECTIVE

To identify the contributing factors to contralateral damage, as determined by MRS, and its extension in patients with temporal lobe epilepsy.

METHODS

Single voxel MRS was carried out in the hippocampus and lateral temporal neocortex of both hemispheres in 13 patients with left temporal lobe epilepsy (LTLE) and 16 patients with right temporal lobe epilepsy (RTLE). All patients had mesial temporal lobe epilepsy with hippocampal sclerosis. Controls were 21 healthy volunteers of comparable age.

RESULTS

Consistent with previous studies, the NAA/(Cho+Cr) ratio was abnormally low in the hippocampus ipsilateral to the focus (p < 0.0001), and there were lower values in both patient groups in the ipsilateral temporal neocortex (p < 0.0001). Patients with RTLE had left hippocampal MRS anomalies (p = 0.0018), whereas the right hippocampus seemed to be undamaged in LTLE patients.

CONCLUSIONS

Unilateral mesial temporal lobe epilepsy is associated with widespread metabolic abnormalities which involve contralateral mesial and neocortical temporal lobe structures. These abnormalities appear to be more pronounced in patients with RTLE.

The role of cardiac power and systemic vascular resistance in the pathophysiology and diagnosis of patients with acute congestive heart failure

OBJECTIVE

Conventional hemodynamic indexes (cardiac index (CI), and pulmonary capillary wedge pressure) are of limited value in the diagnosis and treatment of patients with acute congestive heart failure (CHF).

PATIENTS AND METHODS

We measured CI, wedge pressure, right atrial pressure (RAP) and mean arterial blood pressure (MAP) in 89 consecutive patients admitted due to acute CHF (exacerbated systolic CHF, n=56; hypertensive crisis, n=5; pulmonary edema, n=11; and cardiogenic shock, n=17) and in two control groups. The two control groups were 11 patients with septic shock and 20 healthy volunteers. Systemic vascular resistance index (SVRi) was calculated as SVRi=(MAP-RAP)/CI. Cardiac contractility was estimated by the cardiac power index (Cpi), calculated as CIxMAP.

RESULTS AND DISCUSSION

We found that CI<2.7 l/min/m(2) and wedge pressure >12 mmHg are found consistently in patients with acute CHF. However, these measures often overlapped in patients with different acute CHF syndromes, while Cpi and SVRi permitted more accurate differentiation. Cpi was low in patients with exacerbated systolic CHF and extremely low in patients with cardiogenic shock, while SVRi was increased in patients with exacerbated systolic CHF and extremely high in patients with pulmonary edema. By using a two-dimensional presentation of Cpi vs. SVRi we found that these clinical syndromes can be accurately characterized hemodynamically. The paired measurements of each clinical group segregated into a specific region on the Cpi/SVRi diagnostic graph, that could be mathematically defined by a statistically significant line (Lambda=0.95). Therefore, measurement of SVRi and Cpi and their two-dimensional graphic representation enables accurate hemodynamic diagnosis and follow-up of individual patients with acute CHF.

Acute heart failure: a novel approach to its pathogenesis and treatment

Acute heart failure (HF) is one of the most common syndromes in emergency medicine, however, its exact pathogenesis has remained largely unknown. Based on clinical and hemodynamic data we have sub-divided acute HF into four syndromes: cardiogenic shock, pulmonary edema, hypertensive crisis and exacerbated HF. Cardiogenic shock is caused by a severe reduction in cardiac power which is not met by an adequate increase in peripheral vascular resistance leading to significant decrease in blood pressure and end organ perfusion. Hence the treatment of cardiogenic shock should be directed at improving cardiac performance (by optimizing filling pressure, intra-aortic balloon pump and immediate revascularization) and administration of peripheral vasoconstrictors. The other acute HF syndromes (pulmonary edema, HTN crisis and exacerbated HF) are caused by a combination of progressive excessive vasoconstriction superimposed on reduced left ventricular functional reserve. The impaired cardiac power and extreme vasoconstriction induce a vicious cycle of afterload mismatch resulting in a dramatic reduction of CO and elevated left ventricular end diastolic pressure, which is transferred backwards to the pulmonary capillaries yielding pulmonary edema. Therefore, the immediate treatment of these acute HF syndromes should be based on the administration of strong, fast-acting intravenous vasodilators such as nitrates or nitroprusside. After initial stabilization, therapy should be directed at reducing recurrent episodes of acute HF, by prevention of repeated episodes of excessive vasoconstriction along with efforts to optimize cardiac function.

Pulmonary edema: new insight on pathogenesis and treatment

Pulmonary edema is one of the most serious and life-threatening situations in emergency medicine. Lately it has become apparent that in most cases pulmonary edema is not caused by fluid accumulation but rather fluid redistribution that is directed into the lungs because of heart failure. Based on a series of recently published studies, we propose that often the pathogenesis of pulmonary edema is related to a combination of marked increase in systemic vascular resistance superimposed on insufficient systolic and diastolic myocardial functional reserve. This resistance results in increased left ventricular diastolic pressure causing increased pulmonary venous pressure, which yields a fluid shift from the intravascular compartment into the pulmonary interstitium and alveoli, inducing the syndrome of pulmonary edema. Therefore, the emphasis in treating pulmonary edema has shifted from diuretics (ie, furosemide) to vasodilators (ie, high-dose nitrates) combined with noninvasive positive airway pressure ventilation and rarely inotropes. New classes of drugs that are currently being investigated for treating decompensated heart failure such as natriuretic peptides, calcium promoters, and endothelin antagonist are also being assessed for treating pulmonary edema. This review will explore this new hypothesis put forward to explain the pathogenesis of pulmonary edema and the evolving management strategies.

High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema

OBJECTIVE

To determine the feasibility, safety and efficacy of bilevel positive airway ventilation (BiPAP) in the treatment of severe pulmonary edema compared to high dose nitrate therapy.

BACKGROUND

Although noninvasive ventilation is increasingly used in the treatment of pulmonary edema, its efficacy has not been compared prospectively with newer treatment modalities.

METHODS

We enrolled 40 consecutive patients with severe pulmonary edema (oxygen saturation <90% on room air prior to treatment). All patients received oxygen at a rate of 10 liter/min, intravenous (IV) furosemide 80 mg and IV morphine 3 mg. Thereafter patients were randomly allocated to receive 1) repeated boluses of IV isosorbide-dinitrate (ISDN) 4 mg every 4 min (n = 20), and 2) BiPAP ventilation and standard dose nitrate therapy (n = 20). Treatment was administered until oxygen saturation increased above 96% or systolic blood pressure decreased to below 110 mm Hg or by more than 30%. Patients whose conditions deteriorated despite therapy were intubated and mechanically ventilated. All treatment was delivered by mobile intensive care units prior to hospital arrival.

RESULTS

Patients treated by BiPAP had significantly more adverse events. Two BiPAP treated patients died versus zero in the high dose ISDN group. Sixteen BiPAP treated patients (80%) required intubation and mechanical ventilation compared to four (20%) in the high dose ISDN group (p = 0.0004). Myocardial infarction (MI) occurred in 11 (55%) and 2 (10%) patients, respectively (p = 0.006). The combined primary end point (death, mechanical ventilation or MI) was observed in 17 (85%) versus 5 (25%) patients, respectively (p = 0.0003). After 1 h of treatment, oxygen saturation increased to 96 +/- 4% in the high dose ISDN group as compared to 89 +/- 7% in the BiPAP group (p = 0.017). Due to the significant deterioration observed in patients enrolled in the BiPAP arm, the study was prematurely terminated by the safety committee.

CONCLUSIONS

High dose ISDN is safer and better than BiPAP ventilation combined with conventional therapy in patients with severe pulmonary edema.

Diuretic therapy in elderly heart failure patients with and without left ventricular systolic dysfunction

Long term prescription of diuretics for heart failure is very prevalent among elderly patients, although the rationale for such a treatment strategy is often unclear, as diuretics are not indicated if volume overload is absent. The concept of diastolic heart failure in the elderly might particularly change the role of diuretic therapy, since diuretics may have additional adverse effects in these patients. This paper reviews the effects of diuretic therapy in elderly patients with heart failure, emphasising the differences between patients with normal and decreased left ventricular systolic function. Studies on diuretic withdrawal in elderly patients with heart failure are discussed, with emphasis on issues involved in decision making such as diuretic dose reduction and withdrawal in elderly patients and factors that have been established to predict successful withdrawal. Existing guidelines on the prescription of diuretics in elderly patients with heart failure with normal and decreased left ventricular systolic function and in those with diastolic heart failure are also discussed. By reducing intravascular volume, diuretics may further impair ventricular diastolic filling in patients with diastolic heart failure and thus reduce stroke volume. Indeed, preliminary studies demonstrate that diuretics may provoke or aggravate hypotension on standing and after meals in these patients. Therefore, it is suggested that elderly patients with heart failure with intact left ventricular systolic function should not receive long term diuretic therapy, unless proven necessary to treat or prevent congestive heart failure. This implies that physicians should carefully evaluate the opportunities for diuretic dose tapering or withdrawal in all of these patients, and that a cautiously guided intermittent diuretic treatment modality may be critical in the care for older patients with heart failure with intact left ventricular systolic function.

Acute Pulmonary Edema

Patients with acute cardiogenic pulmonary edema require rapid assessment and therapy to prevent progression to respiratory failure and cardiovascular collapse. The goal of therapy is to decrease the pulmonary capillary wedge pressure by decreasing intravascular volume and shifting the blood volume into peripheral vascular beds. Mainstays of therapy include morphine sulfate (a venodilator and an anxiolytic), furosemide (a venodilator and diuretic), nitroglycerin preparations (venodilators), and, in some cases, aminophylline, nitroprusside, and beta-adrenergic agents or milrinone. Patients who do not respond to more conservative measures may require interventional procedures, including Swan-Ganz catheterization or arterial pressure monitoring, continuous positive airway pressure or mechanical ventilation, intra- aortic balloon counterpulsation, and mechanical removal of fluid. Because the prognosis for patients with acute cardiogenic pulmonary edema depends on identification and correction of the underlying disease process, it is essential to define the cause of the edema during and after stabilization of the patient. Evaluation should include Doppler echocardiography, cardiac catheterization, and coronary angiography.

Nitrate therapy is an alternative to furosemide/morphine therapy in the management of acute cardiogenic pulmonary edema

BACKGROUND

Nitrates are superior to furosemide in the management of acute pulmonary edema associated with myocardial infarction; however, their role in the absence of infarction is unclear.

METHODS AND RESULTS

A randomized comparison was undertaken of the relative effectiveness of primary therapy with either intravenous morphine/furosemide (men/women; n = 32) or nitroglycerin/N-acetylcysteine (NTG/NAC; n = 37) in consecutive patients with acute pulmonary edema. The primary end point was change in PaO2/FIO2 over the first 60 minutes of therapy. Secondary end points were needed for mechanical respiratory assistance (ie, continuous positive airway pressure via mask or intubation and ventilation) and changes in other gas exchange parameters. Both treatment groups showed improvement in oxygenation after 60 minutes of therapy; however, this reached statistical significance only with NTG/NAC therapy. There was no significant difference between groups in the assessed parameters (95% CI for differences in Pao2/FIO2: furosemide/morphine -12 to 23 and NTG/NAC 4 to 44), a finding also confirmed in 32 patients presenting with respiratory failure. Only 11% of the study group required mechanical ventilatory assistance (continuous positive airway pressure in 4 patients and intubation and ventilation in 3 patients).

CONCLUSIONS

NTG/NAC therapy is as effective as furosemide/morphine in the initial management of acute pulmonary edema, regardless of the presence or absence of respiratory failure. The necessity for mechanical ventilatory assistance is infrequent in these patients, regardless of the initial medical treatment regimen.

Are symptoms the most important target for therapy in chronic heart failure?

Symptoms combined with a loss of quality of life can be considered part of the morbidity of heart failure. Patients with chronic heart failure (CHF) have a poorer quality of life than do those with other chronic conditions including arthritis and lung disease. Although there is no evidence to show a mortality benefit, diuretics are frequently used for symptomatic relief in CHF patients. Angiotensin converting enzyme (ACE) inhibitors have been shown both to improve symptoms and to reduce mortality; however, ACE inhibitors have yet to show any conclusive benefit in improving quality of life. Digoxin is widely used and offers symptomatic relief, but it has been shown to have no overall effect on mortality. More recently, certain beta-blockers have been shown to impact both morbidity and mortality in patients already receiving standard therapy including an ACE inhibitor and diuretics. This article reviews these and additional therapies currently used in the management of CHF in the context of their impact on the joint goals of reducing both morbidity and mortality.

Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema

BACKGROUND

Nitrates and furosemide, commonly administered in the treatment of pulmonary oedema, have not been compared in a prospective clinical trial. We compared the efficacy and safety of these drugs in a randomised trial of patients with severe pulmonary oedema and oxygen saturation below 90%.

METHODS

Patients presenting to mobile emergency units with signs of congestive heart failure were treated with oxygen 10 L/min, intravenous furosemide 40 mg, and morphine 3 mg bolus. 110 patients were randomly assigned either to group A, who received isosorbide dinitrate (3 mg bolus administered intravenously every 5 min; n=56) or to group B, who received furosemide (80 mg bolus administered intravenously every 15 min, as well as isosorbide dinitrate 1 mg/h, increased every 10 min by 1 mg/h; n=54). Six patients were withdrawn on the basis of chest radiography results. Treatment was continued until oxygen saturation was above 96% or mean arterial blood pressure had decreased by 30% or to below 90 mm Hg. The main endpoints were death, need for mechanical ventilation, and myocardial infarction. The analyses were by intention to treat.

FINDINGS

Mechanical ventilation was required in seven (13%) of 52 group-A patients and 21 (40%) of 52 group-B patients (p=0.0041). Myocardial infarction occurred in nine (17%) and 19 (37%) patients, respectively (p=0.047). One patient in group A and three in group B died (p=0.61). One or more of these endpoints occurred in 13 (25%) and 24 (46%) patients, respectively (p=0.041).

INTERPRETATION

High-dose isosorbide dinitrate, given as repeated intravenous boluses after low-dose intravenous furosemide, is safe and effective in controlling severe pulmonary oedema. This treatment regimen is more effective than high-dose furosemide with low-dose isosorbide nitrate in terms of need for mechanical ventilation and frequency of myocardial infarction.