Acute Pulmonary Edema in Late-Stage Heart Failure-Another

Lethal Vicious Circle

A frequent cause of death in heart failure is acute pulmonary edema occurring in patients who
have already had chronic heart failure for a long time. When this occurs in a person without
new cardiac damage, it usually is set off by some temporary overload of the heart, such as
might result from a bout of heavy exercise, some emotional experience, or even a severe cold.
The acute pulmonary edema is believed to result from the following vicious circle:
1. A temporarily increased load on the already weak left ventricle initiates the vicious
circle. Because of limited pumping capacity of the left heart, blood begins to dam up in
the lungs.
2. The increased blood in the lungs elevates the pulmonary capillary pressure, and a small
amount of fluid begins to transude into the lung tissues and alveoli.
3. The increased fluid in the lungs diminishes the degree of oxygenation of the blood.
4. The decreased oxygen in the blood further weakens the heart and also weakens the
arterioles everywhere in the body, thus causing peripheral vasodilation.
5. The peripheral vasodilation increases venous return of blood from the peripheral
circulation still more.
6. The increased venous return further increases the damming of the blood in the lungs,
leading to still more transudation of fluid, more arterial oxygen desaturation, more
venous return, and so forth. Thus, a vicious circle has been established.
Once this vicious circle has proceeded beyond a certain critical point, it will continue until death
of the patient unless heroic therapeutic measures are used within minutes. The types of heroic
therapeutic measures that can reverse the process and save the patient's life include the
following:
1. Putting tourniquets on both arms and legs to sequester much of the blood in the veins
and, therefore, decrease the workload on the left side of the heart
2. Giving a rapidly acting diuretic, such as furosemide, to cause rapid loss of fluid from the
body
3. Giving the patient pure oxygen to breathe to reverse the blood oxygen desaturation, the
heart deterioration, and the peripheral vasodilation
4. Giving the patient a rapidly acting cardiotonic drug, such as digitalis, to strengthen the
heart
This vicious circle of acute pulmonary edema can proceed so rapidly that death can occur in 20
minutes to 1 hour. Therefore, any procedure that is to be successful must be instituted
immediately.