If standard doses of nitrate – NTG (NiTroGlycerin – GTN GlycerylTriNitrate in Commonwealth countries), ISDN (IsoSorbide DiNitrate), or ISMN (IsoSorbide MonoNitrate) improve outcomes for CHF/ADHF (Congestive Heart Failure/Acute Decompensated Heart Failure) patients, and larger IV (IntraVenous) doses are more effective than standard doses,,,,,,,,,,,, what method(s) of drug delivery works best?
High dose IV drip?
High dose IV bolus?
A high dose IV bolus combined with a high dose IV drip?
We performed a retrospective cohort study of patients who presented to the emergency department (ED) of an urban, teaching hospital with severe, acute hypertensive heart failure between Jan 2007 and July 2011 and received intravenous nitroglycerin. 3 subgroups were defined: 1) those given nitroglycerin by higher dose (≥ 0.5 mg) bolus alone (higher dose nitroglycerin); 2) those given nitroglycerin by continuous intravenous infusion alone (intravenous nitroglycerin); and 3) those given nitroglycerin by concurrent higher dose bolus and continuous IV infusion (higher dose intravenous nitroglycerin).
At least half a milligram at a time means at least 25% more than the standard bolus dose with a NTG tab/spray.
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With bolus dosing the blood pressure dropped more quickly.
The sooner we drop the patient’s blood pressure, as long as we do not drop it too much, the better for the patient.
Do we really have a problem with dropping the pressure too much with high doses of bolus IV NTG?
Almost every severely hypotensive patient in this study received more than 1 mg/minute IV NTG, which would be boluses of at least 5 mg IV NTG every 5 minutes until they improved – and most did improve dramatically.
Conclusion: In this single-center, retrospective, unadjusted analysis of primarily African-American patients with acute hypertensive heart failure, nitroglycerin administered by higher dose bolus without concurrent intravenous infusion was associated with a significant decrease in ICU admissions and hospital length of stay. Based on our findings, bolus higher dose nitroglycerin appears to be a viable option for the management of such patients.
There are some important questions about IV bolus dosing of NTG for CHF/ADHF.
How aggressive should our initial bolus dose be?
How often should we repeat the dosing?
NTG is metabolized very quickly, so these boluses are only to treat the initial emergency, then the patient will be switched to an infusion of NTG.
We do need more research, but we also need research that does not include furosemide, or compares furosemide with a placebo.
This evidence is much better than any evidence used to justify epinephrine in cardiac arrest. If any CHF/ADHF patients have a cardiac arrest and they are not immediately resuscitated, they are supposed to be treated with epinephrine according to the current ACLS (Advanced Cardiac Life Support) guidelines.
These patients do not arrest due to any deficiency of adrenaline (epinephrine).
These patients improve with treatment that is essentially the opposite of epinephrine.
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Piyush Mallick, Surjya Upadhyay, TS Senthilnathan, El Matit Waleed , Al Jahra Hospital, Scott Weingart, Mount Sinai School of Medicine
PDF Download of page at EMCrit
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Kwiatkowski GM, Saely S, Purakal J, Mahajan A, Levy PD/Detroit Receiving Hospital, Detroit, MI; Wayne State University School of Medicine, Detroit, MI
Annals of Emergency Medicine, Volume 60, issue 4 (October, 2012), p. S9.
ISSN: 0196-0644 DOI: 10.1016/j.annemergmed.2012.06.049
Abstract 22 Indexed with OhioLINK Journal Article Locator
Kwiatkowski, G.M.; Saely, S.; Purakal, J.; Mahajan, A.; Levy, P.D. (2012). Nitroglycerin for Treatment of Acute, Hypertensive Heart Failure – Bolus, Drip or Both? Annals of Emergency Medicine, 60 (4), 59-59