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Old 08-03-2012
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Drug Drug to treat AF and Pulmonary Edema!

A 63-year-old woman with chest pain is admitted to the coronary care unit. An electrocardiogram shows atrial fibrillation with a ventricular rate of 180 beats/min. The patient shows signs of severe pulmonary edema. Which of the following drugs when given intravenously may relieve this patient’s symptoms?

a) Fludrocortisone
b) Mannitol
c) Meperidine
d) Metoprolol
e) Morphine
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morphine..indicated in pul.edema
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D. Metoprolol.
You can use metoprolol freely here because , unlike in post-MI patients, pulm edema here isn't because of fluid overload(true overload or relative to the pumping capacity of the heart) but because of severe diastolic dysfunction. Slow down the ventricular rate in this patient and he'll be fine.
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d) Metoprolol - IV: 2.5-5 mg over 2-3 min, repeat q5min as needed.
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Correct Answer correct answer :)

The answer is e) Morphine
Intravenous administration of morphine causes a remarkable relief of dyspnea from pulmonary edema associated with left ventricular failure. It decreases the perception of “shortness of breath,” reduces anxiety, and decreases cardiac preload and afterload.

As for Metoprolol - Beta-blockers are contraindicated in patients with cardiogenic shock, acute pulmonary edema, or decompensated systolic congestive heart failure (especially left ventricular dysfunction) because the negative inotropic effect of beta-blockers will further depress cardiac output.


The patient has AF and it's decompensated: pulmonary oedema is a sign of a acute left heart failure -> risk of cardiogenic shock -> beta-blockers contraindicated. If the patient had AF only we could give a beta-blocker.
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I respectfully disagree with the answer, wherever it came from. Firstly, the use of morphine in pulmonary edema is outdated or atleast, its not a firstline drug by a long shot. http://www.bestbets.org/bets/bet.php?id=376
Secondly, there is no rationale to prescribe morphine to this patient because he isn't volume overloaded. You could pump the patient full of morphine, but what will it achieve?
Morphine isn't always =CCF and metoprolol isn't always contradindicated in CCF.
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Originally Posted by smanthrav View Post
I respectfully disagree with the answer, wherever it came from. Firstly, the use of morphine in pulmonary edema is outdated or atleast, its not a firstline drug by a long shot. http://www.bestbets.org/bets/bet.php?id=376
Secondly, there is no rationale to prescribe morphine to this patient because he isn't volume overloaded. You could pump the patient full of morphine, but what will it achieve?
Morphine isn't always =CCF and metoprolol isn't always contradindicated in CCF.
Thanks for your opinion - I understand your point in a way but the thing you're missing here is that the question was "Which of the following drugs when given intravenously may relieve this patient’s symptoms?", so no one asked about the first-line treatment here. The explanation never even suggested the morphine was a first-line treatment.

As for the use of beta-blockers in heart failure (I'm not sure if your CCF meant chronic or congestive cardiac failure) - I didn't say you can't use beta-blockers in those pts - of course (!) you use them eg. in pts with chronic heart failure + AF (metoprolol). I said they are contraindicated in a pt having acute/exacerbation of heart failure going into cardiogenic shock - like in this question.
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Default .

Maybe this image will be more helpful in explaining what I meant
see the attachment
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Drug to treat AF and Pulmonary Edema!-af-decomp-hf.gif  
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