Low- versus high-dose nitroglycerin infusion in the management of acute pulmonary edema.

BACKGROUND: Nitroglycerin (NTG) is commonly used for the management of pulmonary edema in acute heart failure presentations. Although commonly initiated at low infusion rates, higher infusion rates have favorable pharmacodynamic properties and may improve outcomes in the management of acute pulmonary edema. OBJECTIVES: To characterize the clinical outcomes including the time to resolution of severe hypertension when using an initial low dose (<100 µg/min) versus high-dose (≥100 µg/min) strategy. METHODS: This was a retrospective study performed at a single, tertiary academic emergency department in Atlanta, GA. We describe the blood pressure effects and key safety outcomes (intubation, hypotension, intensive care unit admissions) during the first hour of treatment of acute pulmonary edema. RESULTS: 41 patients were included in the final sample. 27 (66%) received low dose NTG and 14 (34%) received high dose NTG. The high dose group reached their blood pressure faster on average (hazard ratio = 3.5, 95% CI: 1.2-10.1). 8/14 (57%) of patients in the high dose group reached their BP target within the first hour of treatment, compared to 6/27 (22%) in the low dose group. Observed incidence of safety outcomes were similar between the two groups. CONCLUSIONS: Higher initial NTG doses may be an effective way to decrease times to achieve blood pressure targets and should be the focus of future trials.