Congestive Heart Failure ======================== þ Bet Blockers for Chronic CHF - Volume 39, Issue 1010 of the Medical Letter discusses several recent trials which demonstrate reduced mortality in patients with NYHA class II or III (mild to moderate) CHF using adjunctive treatment with a combination alpha and beta blocker called carvedilol (trade name, Coreg). The article points out that despite symptomatic improvement with furosemide and digoxin, these latter two drugs have no proven effect on survival (NEJM 1997;336:525). - In one double-blind trial of 366 CHF patients, most already taking digoxin, a diuretic, and an ACE inhibitor, the addition of carvedilol reduced absolute morbidity and mortality from 21% to 11% (Circulation 1996;94:2800). Similar results were obtained in a second trial of 415 patients (Lancet 1997;349:375). A third trial was terminated early due to significant mortality reduction on interim statistical review (NEJM 1996;334:1349). This double-blind trial of 1094 patients demonstrated an absolute mortality reduction from 7.8% with placebo to 3.2% with the addition of carvedilol, again in patients already on digoxin, diuretics, and an ACE inhibitor, and at a median duration of 6.5 months. Significant reduction in hospitalization rates and progression of disease were also noted. - This is strong evidence, akin to both the aspirin and thrombolytic trials demonstrating mortality reduction in MI patients. Such evidence should prompt us, in conjunction with our cardiology and internal medicine colleagues, to begin using this medication in CHF patients who do not have contraindications for its use, particularly since we are using digoxin and furosemide routinely, neither of which appear to have survival benefit. (I'm not advocating tossing out these last two, just pointing out the lack of evidence. Also, nobody has yet answered the question of whether carvedilol by itself reduces mortality.) --James Li, M.D. þ Does CHF respond to albuterol? - yes. þ Prehospital treatment of CHF: þ Role of Oxygen in CHF: þ CHF is primarily a neurohormonal problem, not pump failure. - recent trials show increased mortality from inotropes - vasodilators and inotropes make patients feel worse and do worse. - beta blockers show some benefit in treating CHF [anon. Randomized trials shed new light on CVD treatments. American Heart News 1994:2.] þ Role of Lasix in CHF - For the patient in true pulm.edema not dure to a high output state, lasix is still a mainstay of therapy. The acute effects of IV lasix have been proven to be due initially to increased pulm.venous capacitance since the innovative work of Dikshit et al in anephric patients (lead article in NEJM early '70s). Bob Oatfield, MD. þ Captopril in CHF - captopril in a dose of 25-50 mg SL has been effective in a study presented in an abstract by the Jacoby EM residency at SAEM in 1994. TITLE Rapid improvement of acute pulmonary edema with sublingual captopril [see comments] COMMENTS Comment in: Acad Emerg Med 1996 Mar;3(3):192-3 AUTHOR(S) Hamilton-RJ; Carter-WA; Gallagher-EJ ADDRESS OF AUTHOR New York University, New York, USA. hamilton@is2.nyu.edu SOURCE (BIBLIOGRAPHIC CITATION) Acad-Emerg-Med.1996 Mar; 3(3): 205-12. PUBLICATION YEAR 1996 ABSTRACT OBJECTIVE: To test the hypothesis that sublingual captopril produces a more rapid improvement of acute pulmonary edema (APE) than does placebo, when added to a standard regimen of O2, nitrates, morphine, and furosemide. METHODS: Prospective, randomized, double-blind, placebo-controlled clinical trial in an urban teaching hospital ED. Adults brought to the ED with APE were given captopril or placebo sublingually. Every 5 minutes a clinical APE distress score (APEX) was obtained. RESULTS: Over the first 40 minutes of treatment, the mean APEXs were significantly better for the patients given captopril [p < 0.001, F = 14.5, one-way (repeated-measures) analysis of variance (ANOVA)]. At 30 minutes, the patients given captopril had a mean APEX improvement of 43% (i.e., to 57% of initial distress); the group given the current standard regimen plus placebo improved only 25% (i.e., to 75% of initial distress; p = 0.03, multiway ANOVA). In addition, there was less respiratory failure necessitating mechanical ventilation in the captopril patients (9%) vs the placebo patients (20%), which did not achieve significance (p = 0.10, Fisher's exact test). CONCLUSION: In APE, the addition of sublingual captopril to the standard regimen of O2, nitrates, morphine, and furosemide produces more rapid clinical improvement than does the standard regimen alone. þ NTG IV - boluses of IV NTG found to be effective as reported by AJEM May 1994. þ Diastolic Dysfunction and CHF - Wei. NEJM 1992;327:1735 - Topol. NEJM 1985;312:277 - Kessler Arch IM 1988:148:2109. þ Nipride (nitroprusside): - for "clamped-down" hypertensive patients with CHF: one person recommends 20-40 mcg/min (_not_ per kg) drip. þ milrinone (Primacor): - Inotropic and vasodilator. - Inotropic by different mechanism than digitalis. - Not for acute MIs. - No effect on heart rate. - Can treat up to 5 days. - May increase conduction through AV node and thus increase rate of atrial flutter or atrial fibrillation. - Incompatible with Lasix in IV line. - Main adverse reaction is dysrhythmia: sustained V Tach 1%, V Fib 0.2%. May also cause hypotension in 3%, angina in 1%, and headache in 3%. - dose: 50 ug/kg over 10 minutes, followed by 0.5 ug/kg/min infusion. May need to adjust dosage for renal failure, but not for age. þ Morphine - "I'll merely point out that in a recent consensus statement on the treatment of CHF by an expert panel, the continued use of morphine for acute pulmonary edema uncomplicated by COPD was still being advocated." --H. Louzon MD [Guidelines for the Evaluation and Management of Heart Failure. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure). Circulation 1995;92:2764-2784.] þ AHA-ACC CHF recommendations