Acute and chronic management strategiesBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7234.559 (Published 26 February 2000) Cite this as: BMJ 2000;320:559
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EDITOR - In their review of management of chronic heart failure,
Millane et al mention that low dose spironolactone (25 mg) improves
morbidity and mortality in severe heart failure, when combined with
conventional treatment.1 I would like to relate an experience of its still
lower dose use in a patient of heart failure with underlying renal artery
stenosis; the implication of which may be useful to other patients as
A 71 year old diabetic lady has been having heart failure with
repeated attacks of left ventricular failure for last 3 years. Her
coronary angiogram was normal. Renal arteriography had revealed 80% post
ostial stenosis in right renal artery. Dilatation and stenting of the
lesion had been done 1 year back. She was on enalapril 20 mg twice a day,
carvedilol 12.5 mg twice a day, digoxin 1.25 mg once a day, frusemide 40
mg once a day and insulin. But she continued to have symptoms of heart
failure with blood pressure 150/90 to 120/70. Her condition was more or
less like that as before dilatation and stenting of renal artery. The
patient refused repeat angiogram and possible invasive management of renal
artery. Four months ago spironolactone was also added to her treatment
regimen. It was started with 25 mg a day. After receiving second dose of
spironolactone, her systolic blood pressure fell down to 60 mm Hg. The
drug was stopped. Later it was tried again with 6.25 mg a day. On this
dose, along with other drugs, her blood pressure ranges from 90/60 to
110/70 and she is symptomatically better with no attack of left
ventricular failure. Attempts to increase the dose were associated with
fall in blood pressure, so the 6.25 mg dose of spironolactone was
continued. Her serum creatinine and potassium are within normal limit, as
The 'hyper-response' to spironolactone in this patient apparently
seems to be due to underlying persisting renal artery stenosis. Such
possibility of 'hyper-response' to spironolactone due to renal artery
stenosis or other causes of secondary hyperaldosteronism deserves further
1. Millane T, Jackson G, Gibbs CR, Lip GYH. ABC of heart failure -
Acute and chronic management strategies. BMJ 2000;320:559-62.(26
The patient has given her written consent to publication of her case.
Competing interests: No competing interests
I would like to expand on an aspect of Millane et al's advanced management
strategy in the ABC of heart failure1. Assisted ventilation is mentioned
in the table on page 560, but is not further qualified. It is a somewhat
simplistic view taken by specialists outside critical care areas that
"assisted ventilation" involves sedation and intubation followed by a
period of exile attached to a ventilator in the ICU. This is not without
risk, especially if the need for intubation was questionable in the first
Continuous positive airway pressure applied by a face mask with a tight
seal (mask CPAP) is the evidence based alternative for acute pulmonary
oedema (APO) which may avoid many of the risks associated with intubation.
Physiologically, mask CPAP in APO is associated with reversal of hypoxia,
reduced work of breathing, reduced left ventricular afterload and a
positive effect on myocardial oxygen supply : demand2.
In a recent systematic review of standard therapy versus standard therapy
plus mask CPAP for APO, the pooled data showed a lower intubation rate in
the CPAP group: 14 of 89 v 37 of 90 (risk difference 26%: 95% CI 14 to
38%). This indicated a need to treat 4 patients to avoid 1 intubation. The
same review also showed a trend to decreased mortality in the CPAP group:
9 of 89 v 16 of 90 (risk difference -6.6%: 95% CI -16 to +3%)3. Shorter
length of stay in ICU has also been shown with mask CPAP4.
Mask CPAP applied to patients with APO is not the claustrophobic
instrument of torture it may at first seem to the uninitiated. It is
readily tolerated with simple explanation and the reduction in work of
breathing is translated rapidly into increased patient comfort. Patients
who do not show this by a drop in heart and respiratory rates should be
reconsidered for intubation and mechanical ventilation3. Mask CPAP is
usually required for a few hours during which standard therapy continues
and a diuresis is achieved. Improvement in gas exchange allows a decrease
in FiO2 and discontinuation of CPAP.
Putting this evidence into practice is however, not without problems.
Maximal benefit will be gained by the early application of mask CPAP. In
the UK the equipment and expertise is not available in the vast majority
of areas to which these patients present (A and E and medical units).
Transfer of patients to a critical care area where these are available is
often very difficult and understandably, those involved may feel that the
safer option is sedation and intubation for this transfer subverting the
opportunity to use mask CPAP. Late referral of patients with APO who are
in extremis and have a decreased conscious level may also bypass the
opportunity to intervene with mask CPAP.
The solution to some of these problems lies with the wider availability of
what is a relatively simple piece of equipment allied to timely requests
for critical care expertise and a wider understanding that respiratory
support does not always imply a tube in the trachea.
1. Millane T, Jackson G, Gibbs CR, Lip GYH. ABC of heart failure:
Acute and Chronic Management Strategies. BMJ 2000; 320: 559-62.
2. Duke GJ, Bersten AD. Non-invasive Ventilation for Adult
Respiratory Failure. Part II. Critical Care and Resuscitation 1999; 1: 199
3. Pang D, Keenan SP, Cook DJ, Sibbald WJ. The Effect of Positive
Pressure Airway Support on Mortality and the Need for Intubation in
Cardiogenic Pulmonary Edema. A Systematic Review. Chest 1998; 114:1185-92.
4. Bersten AD, Holt AW, Vedig AE, Skowronski GA, Baggoley CJ.
Treatment of severe cardiogenic pulmonary oedema with continuous positive
airway pressure delivered by face mask. N Engl J Med 1991; 325: 1825-30.
Competing interests: No competing interests