Showing papers by "Andy Jagoda published in 2008"

Opiates and acute pulmonary oedema: addicted to the wrong therapy.

Abstract: We read with interest Dr Sosnowski’s article ‘Lack of effect of opiates in the treatment of acute cardiogenic pulmonary oedema’ in this issue of Emergency Medicine Australasia not only because it helps to dispel the persistent mythology that surrounds the use of i.v. opiates in the treatment of acute pulmonary oedema (APO), but also because it points out several of the fundamental issues that plague the current management of acute decompensated heart failure (ADHF). As is clear from the article, there is a dearth of good evidence to help guide the management of ADHF patients. In the current age of evidence-based medicine, this is worth noting because it places front-line providers in the difficult position of constructing their own treatment algorithms, without the tools typically available to them. Not a small matter given the prevalence and seriousness of the disease in question. Heart failure has reached near epidemic proportions with an estimated 550 000 new cases annually in the United States and a hospitalization rate that has increased 159% during the past decade. Although we have become more successful at treating advanced cardiac disease via aggressive medical and interventional management, we have effectively created a growing population of cardiac cripples, patients who will predictably present with exacerbation of ADHF and APO as their cardiac function progressively declines. Of equal concern, heart failure is a disease with an abysmal prognosis. With mortality rates that exceed those of myocardial infarction at both time points of 30 days and 1 year, there is a strong impetus to continue to improve the ways we provide care for this patient group. Interestingly, despite the tremendous burden heart failure places on the medical system, few prospective randomized trials have been conducted to establish best care. Most of the literature that exists, as reflected in Sosnowski’s current review article, consists of small, poorly designed studies that do little to delineate the true efficacy of individual therapeutic interventions. Given the lack of good evidence to guide their practice, it is not surprising that many clinicians base their treatment decisions on their own experience, as well as the anecdotal reports provided by colleagues and instructors during their training. In this framework, it is understandable that opiates have remained an accepted part of the heart failure treatment regimen, because portions of their therapeutic effect are at least theoretically beneficial in the ADHF/APO patient. The most reasonable argument for using opiates in APO is that they do possess some vasodilatory properties and therefore might potentially improve cardiac output by decreasing preload and afterload. Regardless of whether APO presents in the setting of systolic or diastolic dysfunction, it is a state that is characterized by significant elevation of both systemic vascular resistance (i.e. afterload) and filling pressures (i.e. preload). These altered cardiac loading conditions, in the presence of ventricular dysfunction, prevent adequate forward flow of blood from the left ventricle and result in transmission of elevated pressures into the pulmonary vasculature with the development of pulmonary oedema. As has been increasingly reported, pulmonary oedema might develop with or without significant volume overload, suggesting that the primary issue in APO, and therefore the focus of initial therapy, should