Literature Review: Beta Agonists for Heart Failure

     Maak CA, Tabas JA, McClintock DE. Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who may have heart failure? J Emerg Med, Jun 20, 2008 [e-pub ahead of print].

Abstract
     The goal was to determine the safety and efficacy of acute administration of inhaled beta-2 agonists to patients with heart failure. Medline and EMBASE searches were performed, and bibliographies of relevant articles were searched. Only studies addressing acute effects of beta-2 agonists were included for analysis. Twenty-four studies comprising 434 patients were identified: five studies with inhaled administration and 19 with systemic administration. No study directly evaluated the effects of inhaled beta-2 agonists to patients with acutely decompensated heart failure. Treatment of heart failure patients with beta-2 agonists resulted in transient improvements in pulmonary function and cardiovascular hemodynamics. Only one investigation reported an association between beta-2 agonist use and an increase in malignant dysrhythmias. Investigations in animal models of heart failure and acute lung injury demonstrated resolution of pulmonary edema with beta agonist administration. There is insufficient evidence to suggest that acute treatment with inhaled beta-2 agonists should be avoided in patients with dyspnea who may have heart failure. Based on small studies and indirect evidence, administration of beta-2 agonists to patients with heart failure seems to improve pulmonary function, cardiovascular hemodynamics and resorption of pulmonary edema. Although an increase in adverse effects with the use of beta-2 agonists cannot be ruled out based on these data, there was no evidence of an increase in clinically significant dysrhythmias, especially when administered by inhalation. Based on these findings, further study should focus on the clinical outcomes of patients with acutely decompensated heart failure who are treated with inhaled beta-2 agonist therapy.

Comment
     One of the cornerstones of treatment of patients with shortness of breath is to avoid inhaled B agonists (e.g., albuterol) if one suspects heart failure (CHF) as the cause. However, EMS treatment is usually done without a known diagnosis, often in patients with complex histories and multiple medical conditions, and patients with COPD or asthma can go without needed treatment if CHF is a possibility.

     This report suggests that the concern about using inhaled B agonists may be more urban legend than fact. In the studies reviewed here, both human and animal models, there is no evidence that administering this medication worsens CHF, and it may in fact be of benefit.

     Further study is needed to better understand the use of these agents in the prehospital treatment of heart failure, and perhaps someday albuterol may be added to NTG and CPAP to treat CHF. But for now EMS systems may want to review their protocols and at least consider removing suspicion of CHF as an absolute contraindication to the use of B agonists.

EMS BLOGSPOT: Ghost by Peter Canning
     We're called to the cemetery for a woman passed out. I have been here so many times before. It is almost always the same story. Beautiful, clear day, green grass, a procession of cars parked along the road, memoriams white-washed on their back windows. "Remember Julio. R.I.P." And then the gathering of mourners, all dressed in black.

     A small crowd surrounds the woman who sits on the grass, crying, clutching at her heart. A man tells us she passed out, but they caught her before she hit her head. My partner lowers the stretcher, and spreads out a clean sheet on it. I wait while a relative whispers to the woman in Spanish. From where I stand I can look down into the earth and see the white casket with the gold cross on it, red roses draped across it.

     She is quiet in the back on the ride to the hospital. Her eyes still wet, she looks at the ceiling, at the cabinets. Her fingers caress the stretcher rail. I wonder if she knows.

     He was on the same bed. We traveled over this same road as the sirens wailed. Can she feel his presence? Can she hear his voice? "It's okay, mami. It's okay. I'm all right now." Are his arms around her? Can she feel his heart beating inside hers?

Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS Agencies.

Peter Canning has been a full-time paramedic in the Greater Hartford (CT) area since 1995. He is the author of Paramedic: On the Front Lines of Medicine, which relates how he left his desk job as speechwriter for the Governor of Connecticut to become a paramedic on the city streets. Rescue 471: A Paramedic's Stories is the sequel. He started blogging Street Watch: Notes of a Paramedic at www.medicscribe.blogspot.com in 2004. He is also currently at work on Mortal Men, an EMS novel.