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Intravenous sodium nitroprusside substantially reduces afterload and preload; however, its use has been associated with coronary steal.

Digitalis has no role in the management of pulmonary edema complicating STEMI unless rapid AF is present.

Nesiritide (synthetic natriuretic brain peptide) is a new vasodilator agent that promotes diuresis in patients with volume overload and decompensated chronic CHF (class 3 to 4). It has not been investigated in STEMI and is not indicated for treatment of pulmonary edema in these patients. Nesiritide is a potent vasodilator and may result in hypotension, particularly in patients with STEMI, in whom CHF usually is not due to volume overload.

An aldosterone antagonist, eplerenone, was found to be effective for secondary prevention of death and recurrent hospitalization in patients 3 to 14 days after MI with CHF and LVEF less than 0.40. Spironolactone has been demonstrated to improve survival in a population of patients with chronic CHF, which includes those with remote MI.

In contrast to the recommendation to avoid initiation of beta-blockade during pulmonary edema, beta-blockers are strongly recommended before hospital discharge for secondary prevention of cardiac events. The initial dose and titration should be based on clinical heart failure status and LVEF. For patients who remain in heart failure during the hospitalization, a low dose should be initiated and gradually titrated as an outpatient. This is supported by the beneficial effects of beta-blockade in patients with LV dysfunction after STEMI.

A summary of the joined AHA/ACC guidelines for the treatment of patients with pulmonary congestion are provided below:

Class I recommendations

Oxygen supplementation to arterial saturation greater than 90% is recommended for patients with pulmonary congestion. (Level of Evidence: C

Morphine sulfate should be given to patients with pulmonary congestion. (Level of Evidence: C)

ACE inhibitors, beginning with titration of a short-acting ACE inhibitor with a low initial dose (e.g., 1 to 6.25 mg of captopril) should be given to patients with pulmonary edema unless the systolic blood pressure is less than 100 mm Hg or more than 30 mm Hg below baseline. Patients with pulmonary congestion and marginal or low blood pressure often need circulatory support with inotropic and vasopressor agents and/or intra-aortic balloon counterpulsation to relieve pulmonary congestion and maintain adequate perfusion. (Level of Evidence: A)

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