Use of diuretics and nitrates in acute heart failure

Report By: Shiraz Hussain - Medical student
Institution: University of Manchester
Date Submitted: 7th July 2005
Last Modified: 14th July 2005
Status: Blue (submitted but not checked)

Three Part Question

In [adults with moderate to severe acute left ventricular failure] are [diuretics and nitrates together better than nitrates alone] at [reducing mortality]?

Clinical Scenario

A 40 year old man is brought to the A & E department with acute cardiogenic pulmonary oedema. You wonder whether it would be better to treat him with a combination of nitrates and diuretics, or just nitrates alone.

Search Strategy

Medline 1966 to June 2005 week 4
(exp Heart Failure, Congestive/ OR exp Adult/ OR exp Cardiac Output, Low/ OR cardiac failure.mp/ OR ccf.mp/ OR exp Pulmonary Edema/ OR exp Cardiotonic Agents/ OR exp Acute Disease/ OR exp Natriuretic Peptide, Brain/ OR pulmonary edema.mp/ OR pulmonary oedema.mp/ OR exp Ventricular Dysfunction, Left/ OR acute systolic failure.mp/ OR shortness of breath.mp/ OR exp Dyspnea/ OR dyspnoea.mp/ OR exp Morphine/ OR left ventricular failure.mp/ OR lv failure.mp/ OR left ventricular heart failure.mp/ OR lvf.mp.) AND (nitrates.mp. or exp NITRATES/ or (gtn or glyceryl trinitrate).mp. [mp=title, original title, abstract, name of substance word, subject heading word] or exp Coronary Vessels/ or exp Vasodilator Agents/ or exp Nitroglycerin/ or exp Coronary Disease/ or gtn.mp. or exp Heart/ or exp Nitric Oxide/ or glycerin trinitrate.mp.) AND (diuretics.mp. or exp DIURETICS, OSMOTIC/ or exp DIURETICS, THIAZIDE/ or exp DIURETICS/ or exp DIURETICS, SULFAMYL/ or frusemide.mp. or Furosemide/ or furosemide.mp. or exp FUROSEMIDE/)

Search Outcome

237 papers were found
2 were deemed relevant and are included in the BET

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Northridge 1996 Not given	Various depending on study	Review	Pulmonary wedge pressure after frusemide administered	Fell by 34mm Hg within 5 minutes	Aims not clearly stated. Details of study design not included. Details of searches not included. Details of inclusion/exclusion criteria not included. Quality of studies not assessed. Basic data not given. No statistical analysis. Discussion slightly biased.
			Left ventricular filling pressure after nitroprusside infusion	Fell by 36%
			Systemic vascular resistance after nitroprusside infusion	Fell by 27%
			Cardiac output after nitroprusside infusion	Rose by 24%
Cotter et al 1998 Israel	110 patients 52 given mainly nitrates (group A) 52 given mainly diuretics (group B)	RCT	Mean arterial blood pressure (mean values an mm Hg)	Decreased from 132 to 107, p<0.0001, in group A. Decreased from 124 to 103, p<0.0001, in group B. Difference between groups NOT SIGNIFICANT.	Sample size estimation not performed. Details of blinding not given. Respiratory rate differred between the groups at baseline.
			Tracheal intubation and mechanical ventilation	SIGNIFICANTLY lower in group A, p=0.0041
			Myocardial infarction	SIGNIFICANTLY lower in group A, p=0.047
			Pulse + respiratory rates, oxygen saturation	SIGNIFICANTLY higher in group A (values not given)

Clinical Bottom Line

Nitrates and diuretics both have beneficial effects in acute heart failure. Nitrates have been shown to have more benefit than diuretics, but a combination of the two drugs is ideal.

References

Northridge D Frusemide or nitrates for acute heart failure? The Lancet 1996;347(9002):667(2)
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 The Lancet 1998;351(9100):389-393