Management of Cardiogenic Pulmonary Edema (RENAU-OAP)

The prevalence of heart failure is estimated to 2.3 percent of the adult population and strongly increases with age, according to disability-health surveys in France. In recent years, effective treatments (revascularization in percutaneous coronary intervention, circulatory assistance) helped reduce mortality in post-myocardial infarction, which combined with the increase of life expectancy has led to an increase number of patients with chronic heart failure. More than 32,000 annual deaths are attributable to heart failure and the five-year survival rate is similar to those found in cancers of the breast, bladder, colon, ovarian, and prostate. A better therapeutic management (angiotensin converting enzyme inhibitor and beta-blockers) helped reduce mortality after an episode of heart failure requiring hospitalization, but, nevertheless it remains high.

Main clinical manifestations are those of left heart failure, such as cardiogenic pulmonary edema which is a medical emergency. Treatment must take into account pathophysiological aspects of heart failure, etiologies of cardiogenic pulmonary edema and any potential factors or triggers apart from general measures. Two consensus statements and an international recommendation help define therapeutic strategies in this particular situation.

Signs suggestive of cardiogenic pulmonary edema include orthopnea, bilateral crackles or wheezing (patients over 70 years without known asthma), edema of the lower limbs, and gallop sound on heart auscultation. The evolution of these signs makes it particularly possible to manage the response to the treatment. The severity of cardiogenic pulmonary edema depends on several factors such as etiology (ECG analysis and chest pain assessment for acute coronary syndrome), hemodynamic status (blood pressure, heart rate), effect on hematosis (cyanosis, oxygen saturation), and fatigue (low respiratory rate with persistent cardiogenic pulmonary edema signs). The respiratory rate represents a simple clinical feature that can be used to quantify dyspnea (sign of severity if greater than 30 per minute in adults) and then follow its evolution (improvement, exhaustion). Disorders of consciousness can testify to the severity of the hemodynamic state and/or exhaustion.

Cardiogenic pulmonary edema management without shock implies urgent administration of vasodilators (trinitrin) and intravenous loop diuretics in presence of congestion signs along with the establishment of a system of care adapted to severity (Emergency Mobile Services or ambulance, hospitalization in Intensive Care Unit, intensive cardiology unit, cardiology or medicine department, or emergency passage). The subsequent therapeutic management will especially depend on initial treatment by the primary care physician, so it is preferable to record doses and hours of medications. Non-hospitalization must remain exceptional for non-severe decompensation with rapidly favorable evolution.

The French Observatory of Acute Heart Failure (OFICA) including nearly 1,800 patients specified epidemiological and therapeutic data of patients hospitalized for cardiogenic pulmonary edema in 2009. However, this study did not describe the initial management of the Mobile Emergency and Resuscitation Service and emergency services of hospitals. It is important to note that cardiogenic pulmonary edema initial management is decisive. In addition, early and adapted management of cardiogenic pulmonary edema is associated with a shorter hospital stay and reduced hospital mortality.

The Coronary Emergency Network (RESURCOR) within the Northern French Alps Emergency Network (RENAU) is an emergency care system structured in the departments of Isère, Savoie and Haute-Savoie. Its main goal is to help improve emergency management by using regional good practice guidelines (www.renau.org). In this context, projects aiming to evaluate professional practices are developed regularly. Since emergency management of cardiogenic pulmonary edema has not been evaluated, the Northern French Alps Emergency Network offers an approach to improve professional practices by defining and disseminating a guideline on cardiogenic pulmonary edema management which will then be assessed.