Non-invasive Ventilation Does Not Improve Short-Term Mortality in Patients with Acute Cardiogenic Pulmonary Edema
Clinical Question: Does non-invasive ventilation improve survival for patients with acute cardiogenic pulmonary edema?
Background: Acute cardiogenic pulmonary edema is a common medical emergency, but only small trials address outcomes of non-invasive methods of ventilation.
Study Design: A prospective, randomized control study.
Setting: 26 emergency rooms and hospitals in the United Kingdom.
Synopsis: 1,069 patients with a clinical diagnosis of acute cardiogenic pulmonary edema in the emergency room were randomized to one of three treatment strategies: standard oxygen therapy, continuous positive airway pressure (CPAP), or non-invasive intermittent positive pressure ventilation (NIPPV).
There was no significant difference in the seven-day mortality between patients receiving standard oxygen therapy (9.8%) and those treated with non-invasive ventilation (9.5%). Additionally, there was no significant difference in the combined end point of death or intubation within seven days between patients receiving CPAP and NIPPV—the primary end points of the study.
While non-invasive ventilation was associated with greater reductions in dyspnea, heart rate, acidosis, and hypercapnia than was standard oxygen therapy, rates of other secondary outcomes—including tracheal intubation, admission to the critical care unit, myocardial infarction, and 30-day mortality—were similar.
Bottom Line: Although non-invasive ventilation rapidly improves respiratory distress and metabolic disturbances for patients with acute cardiogenic pulmonary edema, it has no effect on short-term mortality or rates of tracheal intubation and admission to ICU.
Citation: Gray A, Goodacre S, Newby D, et al. Non-invasive ventilation in acute cardiogenic pulmonary edema. N Eng J Med. 2008;359:142-151.
Clinical Question: Does the restoration of sinus rhythm in patients with atrial fibrillation and heart failure reduce mortality from cardiovascular causes?
Background: Recent data show rhythm control provides no benefit over rate control among patients with atrial fibrillation, but limited information is available regarding its applicability to patients with heart failure.
Study Design: Multicenter, prospective, double-blind, randomized trial.
Settings: 123 medical centers worldwide.
Synopsis:1,376 patients with a left ventricular ejection fraction of 35% or less, symptoms of heart failure, and a history of atrial fibrillation were randomized (allocation not concealed) either to a rhythm-control (e.g., conversion to sinus rhythm) or rate-control strategy. The primary outcome measured was the time to death from cardiovascular causes. Secondary outcomes included death from any cause, stroke, worsening heart failure, hospitalization, quality of life, cost of therapy, and a composite of death from cardiovascular causes, stroke or worsening heart failure.
Study follow up succeeded with 94% of enrolled patients completing follow up (median=47 months for survivors) or dying. Amiodarone was the drug used most often in the rhythm-control group. Ninety percent of patients received angiotensin converting enzyme inhibitors or angiotensin II receptor blocker, and 90% received anticoagulation.
Among patients with atrial fibrillation and congestive heart failure, the number of deaths from cardiovascular causes was similar in the rate (25%) and rhythm-control group (27%). Furthermore, there were no significant differences in important secondary outcomes, including death from any cause, worsening heart failure, or stroke.
Bottom Line: For patients with heart failure from systolic dysfunction and atrial fibrillation, the routine use of a rhythm-control strategy does not reduce the rate of death from cardiovascular causes as compared with a rate-control strategy.
Citation: Roy D, Talajic M, Nattel S, et al. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008;358:2667-2677.