High dose versus low dose nitroglycerin infusion in the management of hypertensive acute pulmonary edema in an emergency setting: A randomized controlled trial.

STUDY

OBJECTIVE

To compare the effectiveness and safety of high-dose versus low-dose intravenous nitroglycerin for hypertensive acute pulmonary edema in the emergency department.

METHODS

This open-label, pragmatic, parallel randomized controlled trial was conducted in the emergency department of a tertiary care centre in Eastern India. Adults presenting with hypertensive acute pulmonary edema (systolic blood pressure >160 mm Hg or mean arterial pressure >120 mm Hg) were randomized to receive either high-dose nitroglycerin infusion (starting at 100 μg/min, titrated up to 200 μg/min) or low-dose infusion (starting at 10 μg/min, titrated up to 100 μg/min), in addition to standard care including non-invasive ventilation and diuretics. The primary outcome was attainment of predefined clinical resolution endpoints at 3 and 6 h. Secondary outcomes included time to 25% reduction in systolic blood pressure, need for endotracheal intubation, and hypotension.

RESULTS

Sixty-four patients were enrolled, with 32 assigned to each group. At 3 h, clinical resolution occurred in 28 of 32 patients (87.5%) in the high-dose group compared with 16 of 32 patients (53.3%) in the low-dose group (p = 0.003). Time to achieve a 25% reduction in systolic blood pressure was shorter in the high-dose group (p < 0.001). Two patients (6.2%) in the low-dose group required endotracheal intubation compared with none in the high-dose group. No episodes of hypotension were observed in either group.

CONCLUSION

Among patients with hypertensive acute pulmonary edema, high-dose intravenous nitroglycerin achieved more rapid clinical resolution and blood pressure reduction than low-dose infusion, without an observed increase in adverse events.