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Background <p>Acute hypertensive pulmonary edema is a commonly encountered condition in emergency departments, often manifesting as a rapidly deteriorating clinical syndrome known as sympathetic crashing acute pulmonary edema (SCAPE). High-dose intravenous nitroglycerin (HDN) has proven effective in managing such life-threatening cases by reducing afterload and alleviating pulmonary congestion. However, the optimal dosing strategy remains not well established. In this systematic review, we summarized the clinical outcomes associated with different nitroglycerin regimens in the management of acute hypertensive pulmonary edema.</p> Methods <p>We searched PubMed, Scopus, Web of Science (WOS), and the Cochrane Library for studies on HDN in the treatment of acute hypertensive pulmonary edema. A meta-analysis was performed on double-arm studies using Review Manager (version 5.4). Risk ratios (RRs) and mean differences (MDs), with 95% confidence intervals (CIs), were used as effect estimates.</p> Results <p>Nine studies were included: five single-arm and four double-arm. Among studies comparing high- versus low-dose nitroglycerin, one reported blood pressure control within 1&#xa0;h in 57% of patients receiving high-dose compared to 22.2% in the low-dose group. Another study showed faster symptom resolution with high-dose (65.4%) versus low-dose nitroglycerin (11.5%). Across studies, reported outcomes with high-dose nitroglycerin varied, with symptom resolution rates ranging from 65.4 to 96%, ICU admission rates from 4 to 78.6%, intubation rates from 3.8 to 20.9%, hypotension from 0 to 8%, and worsening renal function from 8.5 to 13.4%. Meta-analysis of the four double-arm studies indicated that high-dose nitroglycerin was associated with lower odds of ICU admission and intubation, although the results were not statistically significant (RR = 0.45; 95% CI, 0.06–3.45; RR = 0.47; 95% CI, 0.14–1.53, respectively). Bolus administration, in particular, was associated with significantly fewer ICU admissions (RR = 0.72; 95% CI, 0.62–0.84) and shorter hospital stays (MD =  − 1.4&#xa0;days; 95% CI, − 1.33 to − 0.76). Other outcomes, including hypotensive episodes and the need for intubation, were comparable between the bolus and continuous infusion groups.</p> Conclusion <p>HDN demonstrates advantages over low-dose regimens, with bolus administration significantly associated with reduced ICU admissions and shorter hospital stays. Further research is warranted to compare bolus dosing with continuous high-dose infusion strategies.</p>

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High-Dose Intravenous Nitroglycerin for Acute Hypertensive Pulmonary Edema: A Systematic Review

  • 期刊论文

  • 发表日期：

    2025年8月15日

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  • Eslam Mohammed Rabea,
  • Muhammad M. Elsharkawy,
  • Abdelrahman Hemida

摘要

Background

Acute hypertensive pulmonary edema is a commonly encountered condition in emergency departments, often manifesting as a rapidly deteriorating clinical syndrome known as sympathetic crashing acute pulmonary edema (SCAPE). High-dose intravenous nitroglycerin (HDN) has proven effective in managing such life-threatening cases by reducing afterload and alleviating pulmonary congestion. However, the optimal dosing strategy remains not well established. In this systematic review, we summarized the clinical outcomes associated with different nitroglycerin regimens in the management of acute hypertensive pulmonary edema.

Methods

We searched PubMed, Scopus, Web of Science (WOS), and the Cochrane Library for studies on HDN in the treatment of acute hypertensive pulmonary edema. A meta-analysis was performed on double-arm studies using Review Manager (version 5.4). Risk ratios (RRs) and mean differences (MDs), with 95% confidence intervals (CIs), were used as effect estimates.

Results

Nine studies were included: five single-arm and four double-arm. Among studies comparing high- versus low-dose nitroglycerin, one reported blood pressure control within 1 h in 57% of patients receiving high-dose compared to 22.2% in the low-dose group. Another study showed faster symptom resolution with high-dose (65.4%) versus low-dose nitroglycerin (11.5%). Across studies, reported outcomes with high-dose nitroglycerin varied, with symptom resolution rates ranging from 65.4 to 96%, ICU admission rates from 4 to 78.6%, intubation rates from 3.8 to 20.9%, hypotension from 0 to 8%, and worsening renal function from 8.5 to 13.4%. Meta-analysis of the four double-arm studies indicated that high-dose nitroglycerin was associated with lower odds of ICU admission and intubation, although the results were not statistically significant (RR = 0.45; 95% CI, 0.06–3.45; RR = 0.47; 95% CI, 0.14–1.53, respectively). Bolus administration, in particular, was associated with significantly fewer ICU admissions (RR = 0.72; 95% CI, 0.62–0.84) and shorter hospital stays (MD =  − 1.4 days; 95% CI, − 1.33 to − 0.76). Other outcomes, including hypotensive episodes and the need for intubation, were comparable between the bolus and continuous infusion groups.

Conclusion

HDN demonstrates advantages over low-dose regimens, with bolus administration significantly associated with reduced ICU admissions and shorter hospital stays. Further research is warranted to compare bolus dosing with continuous high-dose infusion strategies.