Ultra‐high dose intravenous nitroglycerin in an ESRD patient with acutely decompensated heart failure

Abstract

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Nitroglycerin Use in the Emergency Department: Current Perspectives

“…Recent studies have found that the use of high-dose intravenous (IV) NTG (>2 mg IV boluses every 3 to 5 min) in this setting may provide significant advantages over traditional treatment dosages. 4 , 25 A recent case report used ultrahigh dose boluses (with doses up to 16 mg), which is markedly higher than the 1–2 mg NTG traditionally given, and was shown to successfully stabilize a patient with acute cardiogenic pulmonary edema and markedly elevated BP. 25 …”

“… 4 , 25 A recent case report used ultrahigh dose boluses (with doses up to 16 mg), which is markedly higher than the 1–2 mg NTG traditionally given, and was shown to successfully stabilize a patient with acute cardiogenic pulmonary edema and markedly elevated BP. 25 …”

“…61 , 62 There have also been reports of nitroglycerin-induced asystole. 63 Nonetheless, NTG has been a longstanding mainstay for treating angina and ACS and is generally well tolerated with a low risk for major adverse events even when used at exceptionally high doses (up to 121 mg sublingual and transdermal 64 or 56 mg IV bolus 25 ). NTG use in pregnancy is also perceived to be of low risk; however, NTG does cross the placenta and is detectable in the umbilical cord/fetal serum.…”

“…Recent studies have found that the use of high-dose intravenous (IV) NTG (>2 mg IV boluses every 3 to 5 min) in this setting may provide significant advantages over traditional treatment dosages. 4,25 A recent case report used ultrahigh dose boluses (with doses up to 16 mg), which is markedly higher than the 1-2 mg NTG traditionally given, and was shown to successfully stabilize a patient with acute cardiogenic pulmonary edema and markedly elevated BP. 25 Although NTG's vasodilatory effect and relatively short half-life make it an ideal treatment option for patients with AHF, elevated BP, and acute cardiogenic pulmonary edema, 6 the aggressive dosing presented above needs further investigation to see if its effect will remain safe and effective for a broader group of patients presenting with acute hypertensive heart failure.…”

“…4,25 A recent case report used ultrahigh dose boluses (with doses up to 16 mg), which is markedly higher than the 1-2 mg NTG traditionally given, and was shown to successfully stabilize a patient with acute cardiogenic pulmonary edema and markedly elevated BP. 25 Although NTG's vasodilatory effect and relatively short half-life make it an ideal treatment option for patients with AHF, elevated BP, and acute cardiogenic pulmonary edema, 6 the aggressive dosing presented above needs further investigation to see if its effect will remain safe and effective for a broader group of patients presenting with acute hypertensive heart failure. Regardless, in unstable patients with hypertensive AHF, nitroglycerin should be provided as soon as feasible 26 as either an NTG IV infusions targeting a dose of 200-400 µg/min or by repeated intravenous boluses of up to 2 mg administered every 3 to 5 minutes.…”