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

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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 OR exp pulmonary edema OR pulmonary OR pulmonary] AND [nitrate$.mp OR exp nitroglycerin OR OR OR glyceryl OR exp isosorbide dinitrate OR isosorbide OR isosorbide] AND [exp furosemide OR OR OR exp bumetanide OR OR exp diuretics OR loop diuretic$.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.

    Table 1


    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


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