Nitroglycerine en astma cardiale

[vesalius]

Enkele quotes uit de beperkte studies die er over dit onderwerp pre-hospitaal gedaan zijn:

High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema.

METHODS:
We enrolled 40 consecutive patients with severe pulmonary edema (oxygen saturation <90% on room air prior to treatment). All patients received oxygen at a rate of 10 liter/min, intravenous (IV) furosemide 80 mg and IV morphine 3 mg. Thereafter patients were randomly allocated to receive 1) repeated boluses of IV isosorbide-dinitrate (ISDN) 4 mg every 4 min (n = 20), and 2) BiPAP ventilation and standard dose nitrate therapy (n = 20). Treatment was administered until oxygen saturation increased above 96% or systolic blood pressure decreased to below 110 mm Hg or by more than 30%. Patients whose conditions deteriorated despite therapy were intubated and mechanically ventilated. All treatment was delivered by mobile intensive care units prior to hospital arrival.
RESULTS:
Patients treated by BiPAP had significantly more adverse events. Two BiPAP treated patients died versus zero in the high dose ISDN group. Sixteen BiPAP treated patients (80%) required intubation and mechanical ventilation compared to four (20%) in the high dose ISDN group (p = 0.0004). Myocardial infarction (MI) occurred in 11 (55%) and 2 (10%) patients, respectively (p = 0.006). The combined primary end point (death, mechanical ventilation or MI) was observed in 17 (85%) versus 5 (25%) patients, respectively (p = 0.0003). After 1 h of treatment, oxygen saturation increased to 96 +/- 4% in the high dose ISDN group as compared to 89 +/- 7% in the BiPAP group (p = 0.017). Due to the significant deterioration observed in patients enrolled in the BiPAP arm, the study was prematurely terminated by the safety committee.

Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema.

METHODS:
Patients presenting to mobile emergency units with signs of congestive heart failure were treated with oxygen 10 L/min, intravenous furosemide 40 mg, and morphine 3 mg bolus. 110 patients were randomly assigned either to group A, who received isosorbide dinitrate (3 mg bolus administered intravenously every 5 min; n=56) or to group B, who received furosemide (80 mg bolus administered intravenously every 15 min, as well as isosorbide dinitrate 1 mg/h, increased every 10 min by 1 mg/h; n=54). Six patients were withdrawn on the basis of chest radiography results. Treatment was continued until oxygen saturation was above 96% or mean arterial blood pressure had decreased by 30% or to below 90 mm Hg. The main endpoints were death, need for mechanical ventilation, and myocardial infarction. The analyses were by intention to treat.
FINDINGS:
Mechanical ventilation was required in seven (13%) of 52 group-A patients and 21 (40%) of 52 group-B patients (p=0.0041). Myocardial infarction occurred in nine (17%) and 19 (37%) patients, respectively (p=0.047). One patient in group A and three in group B died (p=0.61). One or more of these endpoints occurred in 13 (25%) and 24 (46%) patients, respectively (p=0.041).

Current treatment options for early management in acute decompensated heart failure

Hypotension at presentation is uncommon, negating worries about treatment-induced hypotension. In the Acute Decompensated Heart Failure National Registry (ADHERE), in over 100,000 patient presentations to hospital with ADHF, less than 5% of the total population were hypotensive (systolic blood pressure less than 100 mmHg)

Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis.

METHODS:
This study was designed as a nonrandomized, open-label, single-arm study of high-dose nitroglycerin. Patients with hypertension (systolic blood pressure > or = 160 mm Hg or mean arterial pressure > or = 120 mm Hg) who were refractory to initial therapy were eligible for inclusion. Enrolled patients began receiving a titratable nitroglycerin infusion and were given a bolus of high-dose nitroglycerin (2 mg). Repeated administration of high-dose nitroglycerin was allowed every 3 minutes, up to a total of 10 doses. Predefined effectiveness and safety outcomes were tracked throughout hospital admission. To provide a frame of reference for these outcomes, data were retrospectively compiled for similar patients with severe decompensated heart failure who did not receive high-dose nitroglycerin.
RESULTS:
Twenty-nine patients received high-dose nitroglycerin. Endotracheal intubation was required in 13.8% of patients, bilevel positive airway pressure (BiPAP) ventilation in 6.9%, and ICU admission in 37.9%. Symptomatic hypotension developed in 1 patient (3.4%), and biomarker evidence of myocardial infarction was found in 17.2% of patients. The mean dose of high-dose nitroglycerin was 6.5 mg (+/-3.4). For patients who were treated without high-dose nitroglycerin (n=45), endotracheal intubation occurred in 26.7%, BiPAP in 20.0%, and ICU admission in 80.0%. None of these patients developed symptomatic hypotension, and biomarker evidence of myocardial infarction was observed in 28.9% of patients.

Grootste nadeel is wel dat in bovenstaande studies met name gekeken wordt naar korte-termijnresultaten en dat de aantallen te laag zijn om echt harde conclusies te kunnen trekken. Toch denk ik zelf we dat er wel wat te zeggen valt voor hogere doseringen nitroglycerine, welke dosering zal nog uit goed opgezet onderzoek moeten blijken.

De ESC-guidelines zijn naar mijn idee echt veel te conservatief  

[kaasje]

[offtopic][noob]
Vet dynamiet gebruiken om iemand beter te maken
[/noob][/offtopic]

[Joffry Ambu-Vpk]

Pre en afterload verlagen dmv afwateren (furosemide etc) gaat niet zo snel, NTG werkt sneller en effectiever, daarom mag de dosis best wat hoger dan de huidige gehanteerde doses.

Overigens is er ookal wat discussie over de dosis furosemide bij decompensatio cordis patienten,en bij beide groepen ook de dosis in relatie met het gewicht van de patient, de standaarddosis 80 mg lasix kan al erg veel zijn voor een fragiele dame van 45 kg, maar te weinig bij een obese man van 130 kg....