Comparative efficacy and safety of urapidil and nitroglycerin for blood pressure control in acute cardiogenic pulmonary edema.

BACKGROUND

Acute cardiogenic pulmonary edema (ACPE) is a life-threatening manifestation of acute heart failure characterized by abrupt pulmonary congestion and hypertension. Rapid blood pressure (BP) reduction with intravenous vasodilators is a cornerstone of emergency management. Nitroglycerin is widely used but may be limited by side effects, while urapidil, an α1-adrenergic antagonist with additional central serotonergic activity, has been proposed as an alternative.

METHODS

In this prospective cohort study at a tertiary university emergency department, adults with hypertensive ACPE received either intravenous nitroglycerin or urapidil as part of initial management. Hemodynamic parameters were recorded at baseline and every 30 min up to 330 min. The primary outcome was achievement of target systolic BP (<140 mmHg). Secondary outcomes included time-resolved changes in systolic/diastolic BP and heart rate, need for rescue therapy, mechanical ventilation, disposition, and adverse events.

RESULTS

A total of 296 patients were analyzed (nitroglycerin n = 142, urapidil n = 154; median age 69 years, 51 % female). Urapidil achieved earlier and higher cumulative attainment of the BP target from 60 min onward (p < 0.001) and produced faster early declines in systolic/diastolic BP and heart rate. However, invasive mechanical ventilation (13.6 % vs. 6.3 %, p = 0.038) and intensive care admissions (55.2 % vs. 38.7 %, p = 0.010) were more frequent with urapidil. Rescue therapy was required more often with nitroglycerin (28.2 % vs. 16.9 %, p = 0.020). Headache occurred more frequently with nitroglycerin, while other adverse events were comparable.

CONCLUSION

In hypertensive ACPE, urapidil reaches blood pressure targets in a more timely manner, but may be associated with higher rates of endotracheal intubation and ICU admission in this cohort. These observations may support consideration of nitroglycerin when early clinical stabilization is prioritized, while urapidil remains a reasonable alternative. Safety profiles were broadly similar, aside from more frequent headaches with nitroglycerin.