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Use of diuretics and nitrates in acute heart failure

Three Part Question

In [adults with moderate to severe acute left ventricular failure] are [diuretics and nitrates together better than nitrates alone] at [reducing mortality]?

Clinical Scenario

A 40 year old man is brought to the A & E department with acute cardiogenic pulmonary oedema. You wonder whether it would be better to treat him with a combination of nitrates and diuretics, or just nitrates alone.

Search Strategy

Medline 1966 to June 2005 week 4
(exp Heart Failure, Congestive/ OR exp Adult/ OR exp Cardiac Output, Low/ OR cardiac OR OR exp Pulmonary Edema/ OR exp Cardiotonic Agents/ OR exp Acute Disease/ OR exp Natriuretic Peptide, Brain/ OR pulmonary OR pulmonary OR exp Ventricular Dysfunction, Left/ OR acute systolic OR shortness of OR exp Dyspnea/ OR OR exp Morphine/ OR left ventricular OR lv OR left ventricular heart OR AND ( or exp NITRATES/ or (gtn or glyceryl trinitrate).mp. [mp=title, original title, abstract, name of substance word, subject heading word] or exp Coronary Vessels/ or exp Vasodilator Agents/ or exp Nitroglycerin/ or exp Coronary Disease/ or or exp Heart/ or exp Nitric Oxide/ or glycerin AND ( or exp DIURETICS, OSMOTIC/ or exp DIURETICS, THIAZIDE/ or exp DIURETICS/ or exp DIURETICS, SULFAMYL/ or or Furosemide/ or or exp FUROSEMIDE/)

Search Outcome

237 papers were found
2 were deemed relevant and are included in the BET

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Not given
Various depending on studyReviewPulmonary wedge pressure after frusemide administeredFell by 34mm Hg within 5 minutesAims not clearly stated. Details of study design not included. Details of searches not included. Details of inclusion/exclusion criteria not included. Quality of studies not assessed. Basic data not given. No statistical analysis. Discussion slightly biased.
Left ventricular filling pressure after nitroprusside infusionFell by 36%
Systemic vascular resistance after nitroprusside infusionFell by 27%
Cardiac output after nitroprusside infusionRose by 24%
Cotter et al
110 patients 52 given mainly nitrates (group A) 52 given mainly diuretics (group B)RCTMean arterial blood pressure (mean values an mm Hg)Decreased from 132 to 107, p<0.0001, in group A. Decreased from 124 to 103, p<0.0001, in group B. Difference between groups NOT SIGNIFICANT.Sample size estimation not performed. Details of blinding not given. Respiratory rate differred between the groups at baseline.
Tracheal intubation and mechanical ventilationSIGNIFICANTLY lower in group A, p=0.0041
Myocardial infarctionSIGNIFICANTLY lower in group A, p=0.047
Pulse + respiratory rates, oxygen saturationSIGNIFICANTLY higher in group A (values not given)

Clinical Bottom Line

Nitrates and diuretics both have beneficial effects in acute heart failure. Nitrates have been shown to have more benefit than diuretics, but a combination of the two drugs is ideal.


  1. Northridge D Frusemide or nitrates for acute heart failure? The Lancet 1996;347(9002):667(2)
  2. Cotter G, Metzkor E, Kaluski E et al Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema The Lancet 1998;351(9100):389-393