Skip to main content

Main menu

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Letters

Acute decompensated heart failure

Larry A. Allen and Christopher M. O'Connor
CMAJ July 17, 2007 177 (2) 175-176; DOI: https://doi.org/10.1503/cmaj.1070063
Larry A. Allen MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Christopher M. O'Connor MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Responses
  • Metrics
  • PDF
Loading
  • © 2007 Canadian Medical Association or its licensors

[The authors respond:]

In our review, in particular in the section on loop diuretics, we attempted to outline many of the controversies associated with the treatment of volume overload in acute decompensated heart failure.1 We provided 3 references to support the statement that use of loop diuretics in the acute setting is associated with increased mortality. We highlighted the potentially detrimental vasoconstrictive properties of furosemide. We also recognized the importance of alternative approaches, including therapy with vasodilators and positive airway pressure.

Joe Nemeth is correct that elevation of pulmonary capillary wedge pressure (“congestion”) is not necessarily equivalent to volume overload. However, it is our understanding that the vast majority of patients in this situation do have total body volume overload, as evidenced by edema, increased venous filling pressures and hemodilution.2–5 From our clinical experience we would argue for some form of volume reduction therapy as part of the overall treatment strategy for most patients presenting with worsened heart failure and signs of congestion. Few clinicians would dispute that removing fluid from such patients makes them feel better. To further study these issues, we are participating in the development of a randomized trial sponsored by the National Institutes of Health Heart Failure Network in which low and high doses of furosemide will be compared in the treatment of acute decompensated heart failure.

The dose conversions for sublingual to intravenous nitroglycerin provided by Howard Smithline are very helpful. Patients with marked hypertension who tolerate sublingual nitroglycerin may certainly be started at relatively higher doses than we recommended in our article. However, the effect of a single dose of sublingual nitroglycerin is typically short-lived, so direct comparison with a continuous infusion of nitroglycerin may not be appropriate. Hypotension is problematic in the management of such patients and consequently we use a conservative approach, starting with a relatively low dose of intravenous nitroglycerin that is then titrated upward rapidly as tolerated by the patient, as evidenced by hemodynamic measurements and symptoms.

Footnotes

  • Competing interests: None declared for Dr. Allen. Dr. O'Connor has acted as a consultant to and has received speaker fees from Pfizer, GlaxoSmithKline, Medtronic and NitroMed.

REFERENCES

  1. 1.↵
    Allen LA, O'Connor CM. Management of acute decompensated heart failure. CMAJ 2007;176(6):797-805.
    OpenUrlAbstract/FREE Full Text
  2. 2.↵
    Androne AS, Katz SD, Lund L, et al. Hemodilution is common in patients with advanced heart failure. Circulation 2003;107(2):226-9.
    OpenUrlAbstract/FREE Full Text
  3. 3.
    Drazner MH, Rame JE, Stevenson LW, et al. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001;345(8):574-81.
    OpenUrlCrossRefPubMed
  4. 4.
    Adams KF, Fonarow GC, Emerman CL, et al. Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J 2005;149(2):209-16.
    OpenUrlCrossRefPubMed
  5. 5.↵
    Binanay C, Califf RM, Hasselblad V, et al; Escape Investigators and Escape Study Coordinators. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA 2005;294(13):1625-33.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 177 (2)
CMAJ
Vol. 177, Issue 2
17 Jul 2007
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Acute decompensated heart failure
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Acute decompensated heart failure
Larry A. Allen, Christopher M. O'Connor
CMAJ Jul 2007, 177 (2) 175-176; DOI: 10.1503/cmaj.1070063

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
Acute decompensated heart failure
Larry A. Allen, Christopher M. O'Connor
CMAJ Jul 2007, 177 (2) 175-176; DOI: 10.1503/cmaj.1070063
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Footnotes
    • REFERENCES
  • Responses
  • Metrics
  • PDF

Related Articles

  • No related articles found.
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Dare we hope
  • Coexisting failures do not diminish the stature of a giant
  • Highlighting obesity as a risk factor for endometrial cancer
Show more Letters

Similar Articles

Collections

  • Topics
    • Emergency medicine
    • Cardiology: heart failure

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions

Copyright 2021, Joule Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

Powered by HighWire