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PACU Literature Review #18. High-dose Nitroglycerin

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Literature Review #18. High-dose Nitroglycerin

Riszel February 15, 2023

Houseman BS, Martinelli AN, Oliver WD, Devabhakthuni S, Mattu A. High-dose nitroglycerin infusion description of safety and efficacy in sympathetic crashing acute pulmonary edema: The HI-DOSE SCAPE study. Am J Emerg Med. 2023;63:74-78.
PMID: 36327753


  • Sympathetic crashing acute pulmonary edema (SCAPE) is caused when severe, acute elevation in blood pressure results in acute heart failure and fluid accumulation in the lungs. In addition to non-invasive positive pressure ventilation, high-dose nitroglycerin (HDN) has become a mainstay of treatment, however an optimal dosing strategy has not been established


  • To describe the characteristics and outcomes of patients who received an infusion of HDN for the management of SCAPE


  • Retrospective chart review at an adult ED within a large, tertiary care academic medical center

Study Intervention & Comparison

  • HDN infusion (rate ≥100 mcg/min within the first hour)


  • Dosing
    • Median initial rate: 100mcg/min, median peak rate: 200mcg/min
    • 48% received initial bolus (63% oral, 38% IV)
  • Efficacy
    • Median SBP decrease 32% from HDN alone
    • Median SBP decrease 37% from HDN + loop diuretic
  • Safety
    • 31% of patients experienced an unfavorable outcome (intubation (21%), hypotension (4%), or AKI (13%))
    • Baseline SaO2 significantly lower in those with an unfavorable outcome (94% vs 98% p=0.004)


  • Although optimal initial rates and titration strategies remain unknown, high dose nitroglycerin may be a safe alternative strategy to the use of intermittent bolus nitroglycerin in patients with SCAPE.

Additional Readings

  • Paone S, Clarkson L, Sin B, Punnapuzha S. Recognition of sympathetic crashing acute pulmonary edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med. 2018;36(8):1526.e5–7.
  • Stemple K, Dewitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitro- glycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2020 Jun;44:262–6.