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Best evidence topic report
Frusemide or nitrates in acute left ventricular failure
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  1. Annette Johnson,
  2. Kevin Mackway-Jones
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK

    http://dx.doi.org/10.1136/emj.18.1.59-a

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      Report by Annette Johnson, Specialist Registrar Search checked by Kevin Mackway-Jones, Consultant

      Clinical scenario

      An 80 year old man is brought into the emergency department in the early hours of the morning with acute shortness of breath. He is pale, clammy and very distressed. You diagnose acute left ventricular failure. You have heard that frusemide may increase vascular resistance and wonder whether nitrates should be used instead.

      Three part question

      In [patients with acute left ventricular failure] is [frusemide better than nitrates] at [reducing symptoms and avoiding the need for intubation]?

      Search strategy

      Medline 1966–09/00 using the OVID interface. ([exp heart failure, congestive OR exp ventricular dysfunction, left OR left ventricular failure.mp OR exp pulmonary edema OR pulmonary edema.mp OR pulmonary oedema.mp] AND [nitrate$.mp OR exp nitroglycerin OR nitroglycerin.mp OR gtn.mp OR glyceryl trinitrate.mp OR exp isosorbide dinitrate OR isosorbide dinitrate.mp OR isosorbide mononitrate.mp] AND [exp furosemide OR furosemide.mp OR frusemide.mp OR exp bumetanide OR bumetanide.mp OR exp diuretics OR loop diuretic$.mp]) LIMIT to human AND english.

      Search outcome

      Altogether 116 papers found of which 112 were irrelevant or of insufficient quality. The remaining four papers are shown in table 1.

      View this table:
      Table 1

      Comments

      There are still no large trials looking directly at this question. The majority of this work was carried out on patients with recent myocardial infarction.

      Clinical bottom line

      Nitrates have some benefit as the first line pharmacological treatment of acute pulmonary oedema.

      Report by Annette Johnson, Specialist Registrar Search checked by Kevin Mackway-Jones, Consultant

      References

      1. Nelson GI, Silke B, Ahuja RC, et al. Haemodynamic advantages of isosorbide dinitrate over frusemide in acute heart failure following myocardial infarction. Lancet1983;i:730–3.
      2. Verma SP, Silke B, Hussain M, et al. First-line treatment of left ventricular failure complicating acute myocardial infarction: a randomised evaluation of immediate effects of diuretic, venodilator, arteriodilator, and positive inotropic drugs on left ventricular function. J Cardiovasc Pharmacol1987;10:38–46.
        OpenUrlPubMedWeb of Science
      3. Cotter G, Metzkor E, Kaluski E, et al. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. Lancet1998;355:389–93.
        OpenUrl
      4. Beltrame JF, Zeitz CJ, Unger SA, et al. Nitrate therapy is an alternative to furosemide/morphine therapy in the manage-ment of acute cardiogenic pulmonary edema. Journal of Cardiac Failure1998;4:271–9.
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