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Some patients with acute decompensated heart failure will present with sympathetic crashing acute pulmonary edema (SCAPE): sudden, severe hypoxemic respiratory failure from pulmonary edema and hypertension. SCAPE demands immediate, often multimodal, intervention. While guidelines recommend starting IV nitroglycerin (NTG) at 5 μg/min, many clinicians initiate higher dosing and escalate rapidly, hoping to accelerate lung function recovery and stave off more intensive interventions such as intubation and ICU admission.
In a single-center retrospective study, researchers compared outcomes among 441 emergency department patients with SCAPE who received NTG initiated at a low dose (<100 μg/min) or a high dose (≥100 μg/min).
Time to weaning patients off oxygen — the study’s primary outcome — was significantly faster in those receiving high-dose versus low-dose NTG (median, 2.7 vs. 3.3 hours).
High-dose NTG was associated with better blood pressure control without excess hypotension, and groups did not differ in intubations, vasopressor use, or ICU admissions. Median ICU length of stay was significantly lower (by 0.5 days) in the high-dose group.
Mortality appeared lower in high-dose patients (1% vs. 4%; P=0.029), although this was unadjusted for confounders (e.g., high-dose patients were more likely to be on bilevel positive airway pressure).
Henry K, et al. Low versus high dosing strategies of intravenous nitroglycerin for the management of sympathetic crashing acute pulmonary edema. Am J Emerg Med 2025 Dec; 98:41 10.1016/j.ajem.2025.08.017.40834833
Comment
Although the high-dose patients arrived sicker, they improved faster than low-dose patients, without added risk. These results align with the instinct to quickly and aggressively reverse the severe hypertension that often causes crashing cardiogenic pulmonary edema. Despite the obvious limitations of a single-center retrospective study, these findings affirm the safety of initiating high-dose IV NTG in the setting of acute pulmonary edema due to decompensated heart failure, potentially reducing ICU length of stay.