Do Medications Affect Vital Signs in the Prehospital Treatment of Acute Decompensated Heart Failure?

Abstract

Introduction. Prehospital treatment of patients with acute decompensated heart failure (ADHF) has been shown to decrease mortality and morbidity. Vital sign changes have been proposed as clinical endpoints in the evaluation of prehospital treatment for this condition. Objective. To examine the effect of prehospital treatments on vital signs among patients with ADHF. Methods. Records of an urban emergency medical services system from September 1, 2002, through September 1, 2003, were queried for patients who had a paramedic impression of shortness of breath or respiratory distress and had received nitroglycerin and/or furosemide. Demographics, initial and repeat vital signs (blood pressure, heart rate, respiratory rate, and oxygen saturation), and medications and doses were collected. Results. Three hundred nineteen patients were included; the average age was 77 (±12) years and 47% were male. Treatments administered to these patients included nitroglycerin, 296 (93%); furosemide, 194 (61%); albuterol, 189 (59%); aspirin, 57 (18%); morphine, 20 (6%); and prehospital intubation, 15 (5%). Patients were initially hypertensive [mean ± standard deviation of systolic blood pressure (SBP) was 167 ±37 mm Hg], tachycardic (heart rate 106 ± 24 beats/min), tachypneic (respiratory rate 33 ± 7 breaths/min), and hypoxic (pulse oximetry 88% ± 9.5%). After treatment, mean changes included decreases (95% confidence interval)

The role of pre‐hospital management in acute heart failure

“…This may be caused by the infrequent administrations of medication. This finding is contrary to a previous study in which pre‐hospital treatment improved vital signs . That study included more unstable patients and the grade of improvement in vital signs seemed to depend on the baseline level.…”

“…However, a higher proportion of de novo patients received pre‐hospital medication compared with CHF patients in our study. Intravenous morphine was more frequently administered for symptom alleviation than in a previous study, in which only 6% of patients received it . Although nitrate spray was commonly administered, nitrate infusion was administered to few patients.…”

Rapid Clinical Assessment of Patients with Acute Heart Failure: First Blood Pressure and Oxygen Saturation – Is That All We Need?

“…However, in these registries the first blood pressure recorded was the first obtained from the chart and probably reflects some prior treatment, as evident by the significantly higher mean blood pressure recorded in the present study versus the values obtained in ADHERE and OPTIMIZE-HF [1, 3, 20]. As it was shown by Sporer et al [32], patients with AHF are a heterogeneous group of patients with significant variability in vital signs. In our study, we specifically examined the prognostic role of the first SBP and Sa O 2 levels obtained before any prehospital interventions, assuming that lower Sa O 2 and SBP are early signs for impending respiratory and circulatory failure.…”

“…In other studies [4, 6, 7,9,10,11,12, 16, 17, 20, 23, 24], lower blood pressure consistently emerges as an independent prognostic factor for higher rates of death. Results from the large cohorts as ADHERE, OPTIMIZE-HF and EuroHeart Failure Survey strongly support the fact that low blood pressure at hospital admission identifies patients who have a poor prognosis despite medical therapy [1,2,3, 19, 20, 28].…”

Prehospital use of furosemide for the treatment of heart failure

“…The relationship of furosemide use and adverse events remains unclear. In a larger study looking at vital sign changes after prehospital treatment of HF in 319 patients receiving various medications, the study did not find any significant improvement in vital signs, specifically in 194 patients who received furosemide 21. To add to the debate, a recent study published by Testani and colleagues suggested that the haemoconcentration that results from diuresis in decompensated HF patients has a significant survival benefit 22…”