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Bolus Nitroglycerin for CHF

February 17, 2017

Short Attention Span Summary

Hit the Nitro
There has been a lot of buzz about bolus IV nitroglycerin (NTG) for acute heart failure patients.  That’s because it’s a good thing.  My practice has been to start a NTG drip at 50 mcg/min and rapidly titrate up while starting BiPAP.  Turns out, I’m a wimp.
In this non-randomized, retrospective observational study from Detroit, patients received either bolus IV NTG (median push dose 2mg…which is a LOT), NTG infusion (median 35 mcg/min), or a combination of NTG bolus and infusion.  About 30% in each group were also started on BiPAP.  Those who received bolus NTG had a lower ICU admission rate: 48% (bolus) vs 69% (infusion) vs 83% (combination) – and reduced length of stay by about 1 day, findings which remained after statistical adjustment.  Bolus NTG did not result in worsening renal function, hypotension, or other adverse outcomes in the bolus patients.  Caveats were that this was in markedly hypertensive patients (all 180s/110s), most of whom had an EF 30-35%, and most patients were African-American, which affects generalizability.

Spoon Feed
In hypertensive patients with acute decompensated heart failure and shortness of breath, bolus IV NTG 1 or 2 mg was safe and reduced ICU admission and length of stay.

It may take me a while to warm up to these enormous NTG doses, but I am seriously considering adding bolus NTG to my crashing heart failure treatment armamentarium.  PharmERToxGuy reviewed this article, and @EMNerd discussed bolus IV NTG on UMEM pearls.

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Am J Emerg Med. 2017 Jan;35(1):126-131. doi: 10.1016/j.ajem.2016.10.038. Epub 2016 Oct 18.

Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure.

Wilson SS1, Kwiatkowski GM1, Millis SR2, Purakal JD2, Mahajan AP2, Levy PD3.

Author information:

1Department of Pharmacy Services, Detroit Receiving Hospital/Detroit Medical Center, Detroit, MI 48201.

2Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, MI 48201.

3Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, MI 48201. Electronic address: plevy@med.wayne.edu.



The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both.


We retrospectively identified 395 patients that received nitroglycerin therapy in the ED for the treatment of AHF over a 5-year period. Patients that received intermittent bolus (n=124) were compared with continuous infusion therapy (n=182) and combination therapy of bolus and infusion (n=89). The primary outcomes were the frequency of intensive care unit (ICU) admission and hospital length of stay (LOS).


On unadjusted analysis, rates of ICU admission were significantly lower in the bolus vs infusion and combination groups (48.4% vs 68.7% vs 83%, respectively; P<.0001) and median LOS (interquartile range) was shorter (3.7 [2.5-6.2 days]) compared with infusion (4.7 [2.9-7.1 days]) and combination (5.0 [2.9-6.7 days]) groups; P=.02. On adjusted regression models, the strong association between bolus nitroglycerin and reduced ICU admission rate remained, and hospital LOS was 1.9 days shorter compared with infusion therapy alone. Use of intubation (bolus [8.9%] vs infusion [8.8%] vs combination [16.9%]; P=.096) and bilevel positive airway pressure (bolus [26.6%] vs infusion [20.3%] vs combination [29.2%]; P=.21) were similar as was the incidence of hypotension, myocardial injury, and worsening renal function.


In ED patients with AHF, intravenous nitroglycerin by intermittent bolus was associated with a lower ICU admission rate and a shorter hospital LOS compared with continuous infusion.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27825693 [PubMed – in process]

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