Heart failure: acute pulmonary oedema: first attack and dopamine use increased the risk of dying

Clinical bottom line (level 1b)

  1. One in seven patients with acute pulmonary oedema died in hospital.
  2. Patients were more likely to survive if they had
    • previous attacks
    • a good recovery following emergency treatment
    • no requirement for dopamine support
    • ventricular arrhythmias
Sardella et al: European Journal of Internal Medicine 1997; 8: 171-176
Expires October 2003

The study

Inception cohort study with objective outcomes, adjusted for confounding factors, validated in an independent set of patients.

Setting: emergency department, acute hospital, Italy

200 patients (aged 46 to 96; mean 77, 56% male) with acute pulmonary edema (dyspnoea, crackles and sweating with pulmonary vascular congestion on chest X-ray)

Factors studied:
  • Clinical features at presentation, therapy required, precipitating factors


    • Patients received furosemide, nitroglycerin iv, cardiac glycosides, morphine, theophylline, nifedipine, sodium bicarbonate and dopamine as required.

    Logistic regression analysis performed on prognostic factors

    ?100% followed for length of hospital stay
    Outcomes studied:
  • death in hospital
  • death in emergency department

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)    		 NNF
    (95% CI)
    death in hospital length of hospital stay 29/200 15%
    (9.6% to 19%)    		 7
    (5 to 10)
    death in emergency department length of hospital stay 9/200 4.5%
    (1.6% to 7.4%)    		 22
    (14 to 61)

    • The following prognostic factors independently predicted survival
      • a history of heart failure and a second or third attack of acute pulmonary edema
      • no dopamine support required
      • peripheral edema without chest crackles on transfer from emergency department to ward
      • presence of ventricular arrhythmias

    Comments

    1. Clinical feature on arrival were dyspnoea (100%), orthopnoea (92%), jugular venous distension (80%), tachypnoea (76%), coarse crackles (59%), cyanosis (47%), fine crackles (39%), cool moist skin (36%), peripheral edema (29%), bronchospasm (17%), cough (13%) and wheeze (12%).
    2. Precipitating factors were identified as
      • rapidly developing heart failure (55%)
      • lung infections (27%)
      • acute myocardial ischemia (22%)
      • incorrect therapy (17%)
      • hypertensive crisis (15%)
      • physical stress (5%)
      • emotional stress (3%)
      • dietary excess (2%)

    Citation

    1. Sardella F, Checchini M, Pierini A, et al: prognostic factors in acute cardiogenic pulmonary edema. European Journal of Internal Medicine 1997; 8: 171-176
    Contributor: Chris Ball and Clare Wotton, October 1999
    Reviewer:

    Clinical Question.
    Patient acute pulmonary edema
    Intervention or Exposure clinical features, therapy
    Outcome death