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HippoEM Reviews - CHF Update

Mel Herbert, MD MBBS FAAEM, Rob Orman, MD, Scott Weingart, MD, Amal Mattu, MD FAAEM, and Al Sacchetti, MD
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Nurses Edition Commentary

Mel Herbert, MD MBBS FAAEM, Lisa Chavez, RN, and Kathy Garvin, RN

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EM:RAP 2014 August - Summary 1 MB - PDF

Our panel of experts breaks down their step by step management of the patient with acute pulmonary edema.

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Chuck S., M.D. -

We have been using the Mattu Sachetti program with SL Ntg and SL Captopril followed by CPAP in our prehospital for at least 12-15 years with great success. Personally I think you treat this diseas better if you don't start an IV. In fact we have been unable to get IV NTG for the past month or so and have been using SL:spray with great success. There was an article in Annals in 2007 looking at very high (relatively) doses of NTG with good success and minimal complications. (started with the equiv of 50 SL tabs)

Paul C Lee MD -

As a cardiologist, I know I will be shot down by the ER docs. But I feel l need to speak to defend the ridicule the podcast threw at the cardiologists.

We follow ACC/AHA or ESC guidelines, not EM-RAP, or ACEP for that matter. For ADHF (acute decompensated heart failure), diuretics has Class 1 indication, LOE B, while iv NTG is Class IIb, LOE A, according to ACC/AHA. Similarly, the ESC 2012 guideline on HF also gave Class 1 LOE B for iv loop diuretic. and Class IIa LOE B for nitrate. Thus, if you go by Evidence Based Medicine, diuretic is still the drug we should use first, because of higher level of recommendation, followed by nitrate.

Now, Cotter et al (Lancet 1998;351:389-393) did suggest that high dose isosorbide + low dose Lasix is superior to high dose Lasix + low dose isosorbide dinitarate in terms of relief of CHF. However, the enthusiasm should be tempered by the fact that people develop tolerance to iv NTG, especially after they leave the ER a few hours later, in the ICU. At a recent talk at the ACC 2014 scientific session, Dr. Uri Elkayam (heart failure guru) concurs with what the EM-RAP triad panel: tdiuretics does not seem to bring PCWP down acutely in ADHF with high BP, and that NTG drip at much higher dose than what people are using (around 100 mcg/min) can bring the PCWP down much faster. Despite the known hemodynamic effect and superiority, there is no outcome study comparing the nitrate based vs diuretic based approach. And superiority in hemodynamic effect does not guarantee better outcome, example, Nesiteride.

The use of captopril or ACE-I in ADHF is only adequately studied in very small studies: Hamilton et al (Academic Emergency Medicine Volume 3, Issue 3, pages 205–212, March 1996) found that it was useful. Iv Vasotec was studied by a Parisian group (Annane et al) Circulation. 1996; 94: 1316-1324, with only 20 patients. The are other small studies, but all with less than 100 patients. Therefore, while clinical experience may suggest that ACE-I acutely may be effective, the level of evidence is very low. ACE-I was not mentioned in the ACC/AHA, ESC guidelines, and was not mentioned in the ACC talk on this subject in 2014.

In summary, guideline supports the use of diuretic and iv NTG, and current evidence gives limited support to using lower dose of diuretic and higher dose of NTG, but there is no outcome data. The acute use of ACE-I may work, but it is not supported by guideline but seems to be supported by only limited outcome data and case reports/ personal experience only.

Michael S. -

If there is a concern about using lasix on patients with reduced renal blood flow in this situation should we also be concerned using ACE-i acutely and causing a worse renal injury?

Nico P. -

I don't think they ridulice cardiologists!
Some of us, In our clinical practice, in Santiago, Chile, we have been using high doses of NTG IV + ACE - I, usually associated to non-invasive ventilation, with great results! I've been doing it with most of my ADHF during the last 6 years. We should publish this at some point, cause the results are amazing. High dose NTG its safe, its effective and make sense; much more sense that starting with high dose diuretics.
One thing are the guidelines, and I agree that you have to know them and follow them, but I believe that what makes you an expert on something is when you know the reasoning that's behind the guidelines and when you know when not to follow them! I don't know how it is in the States, but in the two hospitals that I work, cardiologists hardly ever see a patient with an acute pulmonary edema... once they see them, they are already out of it! At that point, I'm totally comfortable with giving the lasix.
Probably in Chile is easier to do this, because we still don't have all the legal issues that you guys have to deal with!
Greetings from Santiago

Amal M., M.D. -

Guidelines for management of penetrating wounds to the neck typically talk about various zones of injury and whether the patient should be managed initially with angiogram or just go straight to the OR for exploration. Interestingly, they never talk about initially just applying large guaze pads with direct pressure to the wound. Yet that's something we'd all do...even though there's no large studies supporting that practice and it's not in the guidelines. Are we wrong for not limiting our practice to things that have been proven in large studies and have been included in guidelines? Are we practicing non-EBM medicine by applying guaze and direct pressure to the penetrating neck injury? Yes...probably. Does it work? Yes. Should you do it? Yes. Could it save a life? Yes. But there's no large RCTs supporting direct pressure to a bleeding carotid injury.

This is a simple example of the limitation of guidelines. Additionally, the guidelines are not always written with a focus on immediate treatment, within the first minutes of care when patients are in extremis. Penetrating neck wound recs are more intended for the surgeons who care for the patient who survives the initial insult. And guidelines for decompensated HF are written by cardiologists who, I'm guessing, rarely take care of patients in the first hour when the patient is in extremis, in full-blown cardiogenic pulmonary edema with hypoxia and diaphoresis, looking and feeling like they are about to die. In the US, there are no cardiologists caring for these patients in the ED, so their literature doesn't address the first hour. The guidelines are more relevant to care of the patient after initial stabilization and during the in-hospital course. ACC/AHA/ESC guidelines are not relevant to us in the ED in the first hour. Let's stop pretending that those guidelines are written for our patients in extremis.

Regarding ACEIs, a single one-time dose for acute afterload reduction in patients in extremis is all we are talking about. This will not cause problems with renal failure or hyperK. [note--do not use these if the patient has ever had angioedema, though]. There never will be large studies on this because ACEIs are now fairly cheap, so drug companies will not fund these, and modern-day pharmacology research in the field of cardiogenic pulmonary edema is largely pushed by drug companies. Without drug-company funding, there's not much chance of large studies on this.


Yeah, I just got into discussion and printed this lecture for one of our hospitalist regarding the use of diuretics because the patient I felt was fluid depleted with low Na and Cl but obviously in acute heart failure. I didn't want to give lasix. He wanted me to. I just documented as such.

Ross B. -

This is a great segment. Thanks for the thoughts.

I have a couple of questions:
1) In residency I learned about a positive effect of Lasix on Pulm edema patients, in that it had a "primary effect on the Lung Tissue" itself and helped more acutely to move the fluid out of the lung, even prior to the actual diuresis. Is this true? Does it help at all in these severely ill patients?

2) what about patients with severe Aortic Stenosis who are severely hypertensive and have decompensated heart failure? Most guidelines focus on not lowering the preload as these patients are preload dependent, and a recent conversation I had with a cardiologist suggested that afterload reduction would not be beneficial as the majority of the resistance was at the valve itself. It seems to me that these are, effectively, to resistors in series and that if we could lower the resistance of the vascular resistance (afterload) that would help with forward flow and pulm edema. Clearly Noninvasive ventillation is helpful here, but it seems that nitrates are taboo. I'm not sure if other agents such as Ace-I or Nicardipine would be benefitial here or if they affect preload too much as well. Thoughts?

Samuel D. -

I see few patients in true extremis due to CHF exacerbation. As the RN staff is not aggressive with titrating nitro drips, I have been using BiPap, iv vasotec, and one inch of nitro paste.

I'm having difficulty finding what the equivolent serum concentration for nitro paste (ie 0.4 mg Sublingual nitro = 70mcg/min iv nitro).

Could anyone comment on wether this is acceptable and what the serum concentration of topical nitro may be?

Louis V., MD -

I have 3 quick questions on CHF... If the main issue in CHF is fluid in lungs (third spacing), would
1- Would Albumin IV help pull back some fluid from the tissues back into the circulation?
2- If Cardiac dysfuction is an issue, would IV Digitalis help?
3- When pt's with CHF are hypotensive, would Doppamine be a good choice pressor due to increase renal perfusion or dobutamine to help cardiac contractility?


Andrew SAQ, M.D. -

Just had the discussion with our internal medicine scolding me for not starting furosemide in flash pulmonary edema patient with ST elevation in aVR (thank you Dr. Mattu!!!), was previously in renal failure and looked clinically dry to me (for what that's worth).
I will try and gently pass on the learning to our medicine colleagues from EMRAP about diuretics. The patients troponins were 4 and rising, the interventionalists did not want to intervene due to medical issues.

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Episode 155 Full episode audio for MD edition 275:00 min - 131 MB - M4AEM:RAP 2014 août Résumé en Francais Français 65:33 min - 60 MB - MP3EM:RAP 2014 August Aussie Edition Australian 73:57 min - 102 MB - MP3EM:RAP 2014 August Canadian Edition Canadian 30:52 min - 43 MB - MP3EM:RAP 2014 Augusto Resumen Español Español 83:27 min - 77 MB - MP3EM:RAP 2014 August MP3 359 MB - ZIPEM:RAP 2014 August - Summary 1 MB - PDFEM:RAP 2014 August Board Review Questions 379 KB - PDFEM:RAP 2014 August Board Review Answers 421 KB - PDF

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