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Case #8 12/19/07 Congestive heart failing! How aggressive can you be?

December 19th, 2007 · 6 Comments · Cardiovascular Diseases

A 58 y/o female with a history of CHF presents with acute dyspnea.  She is hypertensive 190/120, and has rales up both lung fields.  She is on 100% Non-rebreather, has a respiratory rate of 38, and her saturation is 94%.  CXR confirms pulmonary edema.  You initiate treatment with sublingual nitroglycerine (3 doses) and IV lasix.  The patient responds very little, so you initiate a drip of nitroglycerin and Bipap.  

1. How much nitroglycerine can you give?

Several studies suggest the doses of nitroglycerin commonly used to treat decompensated congestive heart failure are to low.  A recent study at Detroit Receiving Hospital (Detroit, MI) in hypertensive severe decompensated heart failure revealed success at very high doses of Nitroglycerin.  In this study, decompensated heart failure patients not improving after sublingual Nitroglycerin and IV lasix were give a bolus of 2 mg of nitroglycerin IV and then placed on a drip (rapid titration to max of 400 micrograms/min).  Interestingly, in this study, the 2 mg bolus of nitroglycerin could be repeated every 3-5 minutes, to a maximum of 20 milligrams of nitroglycerin in 30 minutes.  With this high dose, the authors found that need for intubation and ICU admission was less (than a comparison group not given high dose nigroglycerin). Although this is only one small study, this is not the first study to suggest our traditional doses of nitroglycerin may not maximize the benefit, and perhaps we may need to rethink our doses.  Larger studies with better out come data are needed before we can definitively identify the ideal dose.    

Elkayam U, Bitar F, Akhter MS, Khan S, Patrus S, Derakhshani M.  Intravenous nitroglycerine in the treatment of decompensated heart failure:  potential benefits and limitations.  

Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R.  Treatmetn of severe decompensated heart failure with high-dose intravenous nitroglycerine: a feasibility and outcome analysis.  Ann Emerg Med 2007. Aug;50(2):144-52.

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6 Comments so far ↓

  • Elizabeth Bascom

    I think it would be reasonable to start with a higher nitrogtt at 80 micrograms and to titrate up for response. I like the idea of high dose nitro with boluses but since there has not been a randomized trail yet I would be reluctant to use it. Although since her BP is high she might be a good candidate.

  • Leo Bunting

    I was one of the co-investigators on this study. The way most patients would repond to the bolus NTG was dramatic. I’ve done it a couple of times since coming to St. John’s with similar results. The only difference is that for the study they had more concentrated NTG for the boluses so that each bolus was only 1 or 2 cc’s. Here we have to use the drip bottles (200mcg/ml), so that each bolus is 10ml. After 10 boluses that’s 200ccs – not terrible, but keep it in mind.

  • Liberty Partridge

    A larger sample size that showed the same outcomes would certainly be convincing. Is there something in the works to do such a study?

  • Marson Ma

    When the blood pressure is extremely high, I have been using 0.8 mg NTG SL as many times as possible to get the pressure down (decrease afterload)…no three SL limit. 0.8 mg SL nitro gives you an effective blood dose of 640 mcg with no volume. I start the IV dose of nitro at 100 mcg/min. I have gone as high as 400 mcg/min. I have been using this therapeutic maneuver since I came out of residency. With the advent of IV vasotec, my nitro drip has not have to go that high to reverse the HTN.

  • Duane Corsi, DO

    Has anybody had any severe negative reactions to the high dose NTG?

  • Brian Dean, DO

    ACEP News 2007 supports high dose NTG for flash pulmonary edema
    they state 3 SL then 200-400 MICrograms/min iv

    also new and old cardio drugs are in development

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