FOAMcast - An Emergency Medicine Podcast · FOAMcast

ACEP Heart Failure Clinical Policy & High Dose Nitrates

·26 min·1 clip

In Levy 2007, 13.8% with bolus nitroglycerin were intubated versus 26.7% without boluses.

1. FOAMcast’s episode on ACEP Heart Failure Clinical Policy & High Dose Nitrates centers on acute heart failure syndrome in emergency medicine. 2. Lauren Westover hosts the episode and says she has been in emergency medicine for almost 10 years. 3. The episode asks which parts of acute pulmonary edema care have changed, and which treatments still matter in 2022. 4. She says the 2007 ACEP policy pushed emergency clinicians toward CPAP and non-invasive ventilation for dyspneic, hypoxemic patients. 5. She says morphine used to be routine for breathlessness and sympathetic surge, but she now describes that practice as dispelled and potentially harmful. 6. The first policy question she highlights is whether lung ultrasound can guide diagnosis of suspected acute heart failure syndrome. 7. She says the policy gives lung ultrasound a Level B recommendation when used with history and physical examination. 8. She quotes meta-analysis performance with positive likelihood ratios from 4.84 to 8.94 and negative likelihood ratios from 0.14 to 0.19. 9. She says bedside B-lines can give a diagnosis within 30 seconds to a minute after the patient arrives. 10. The second question is early diuretics, and she says the 2022 policy finds really no evidence for early administration. 11. She says furosemide may have venodilator effects in about 30 minutes and diuresis in about an hour, but other therapies work faster. 12. She says early diuretics should only be considered when the diagnosis is clear and volume overload is present. 13. The third question is whether any risk tool can safely identify patients for discharge home after acute heart failure syndrome. 14. She says the policy advises not to rely on current risk tools alone, but it gives the Ottawa Heart Failure Risk Scale a role in identifying higher-risk patients who should not go home. 15. She names features in Ottawa Heart Failure Risk Scale examples, including acute ischemic ECG changes, desaturation below 90% on room air or with walking, prior intubation for respiratory distress, tachycardia, and hypoxemia. 16. She says the final and most emphasized recommendation is high-dose nitroglycerin for acute heart failure syndrome with elevated blood pressure. 17. She says the evidence centers on bolus nitroglycerin, often 2 milligrams in Levy 2007, with titration to high infusion rates afterward. 18. She says the main downside is transient hypotension, which she describes as uncommon and short-lived because nitroglycerin has a half-life of about three minutes. 19. The tone is practical and practice-focused, with a first-person emergency medicine style and repeated references to what she does in her own practice. 20. Emergency clinicians managing hypertensive pulmonary edema would likely benefit most, while listeners seeking non-ED cardiology detail may skip it.

As heard by us

A practical look at how acute heart-failure care has shifted toward CPAP, non-invasive ventilation, and high-dose nitroglycerin in the right patients.

Sounding more like a bedside update than a grand theory, the episode follows how acute heart-failure care in the emergency department has moved away from routine intubation and toward CPAP, non-invasive ventilation, and high-dose nitroglycerin for hypertensive patients with…

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You want a sharper way to treat severe, hypertensive acute pulmonary edema.

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