Heart failure: captopril improved acute pulmonary oedema

Clinical bottom line (level 1b-)

  1. Patients with heart failure who were given captopril sublingually, have no clear difference in respiratory failure requiring mechanical ventilation, than those given placebo.
  2. Acute pulmonary edema apex score improved 18% more in the captopril group compared with placebo.
Hamilton et al: Academic Emergency Medicine 1996; 3: 205-212
Expires October 2003

The study

Double-blinded ?concealed randomised trial with intention-to-treat
Setting: teaching hospital, USA

48 patients (aged mean 69 years, 54% male) acute pulmonary oedema (acute onset of dyspnoea, diaphoresis and rales >50% of posterior lung fields), as judged by the emergency department attending physician or resident

Excluded if
  • systolic blood pressure <90 mmHg
  • pregnancy
  • known angiotensin-converting-enzyme inhibitor allergy
  • <18 years old
  • intubation within 15 minutes of arrival at emergency department


    • Control Group: (n = 25, 25 analysed): placebo (lactose powder)
    Experimental Group: (n = 23, 23 analysed): lactose plus 12.5 mg captopril capsules were given to the patients- 2 capsules given sublingually for patients with a systolic blood pressure of = 110 mmHg; 1 capsule given to those with systolic blood pressure between 90 and 110 mmHg

    100% followed for 30 minutes improvement in acute pulmonary edema index (APEX) score, from initial 100%

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    respiratory failure requiring mechanical ventilation 30 minutes 5
    (20.0%)    		 2
    (8.70%)    		 57.0%
    (-103% to 91.0%)    		 11.3%
    (-8.15% to 30.8%)    		 9
    (NNT = 3 to infinity;
    NNH = 12 to infinity)

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    mean improvement of APEX score 25.0%
    ()     		43.0%
    ()     		18.0%
    ( to )

    Comments

    1. The study was too small to show any clear difference in respiratory failure between the two groups.

    Citation

    1. Hamilton RJ, Carter WA, Gallagher EJ: Rapid improvement of acute pulmonary oedema edemaedema with sublingual captopril. Academic Emergency Medicine 1996; 3: 205-212
    Contributor: Clare Wotton and Musab Hayatli, October 1999
    Reviewer:

    Clinical Question.
    Patient acute pulmonary edema Oedema
    Intervention or Exposure captopril
    Comparison placebo
    Outcome more rapid improvement