Bolus Dosing Nitroglycerin in Acute Heart Failure
Wilson, S. S., Kwiatkowski, G. M., Millis, S. R., Purakal, J. D., Mahajan, A. P., & Levy, P. D. (2017). Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. The American Journal of Emergency Medicine,35(1), 126-131. doi:10.1016/j.ajem.2016.10.038
Although vasodilators have only been shown to improve symptoms, with no apparent benefit on mortality and hospital readmission they remain our first choice in acute heart failure with hypertension. Nitroglycerin is one of the primary vasodilators used for patients in acute heart failure with hypertension and when administered in a drip has been found to be correlated with longer hospital admissions and increase costs. Nitroglycerin in high dose bolus has been shown to have greater reduction cardiac afterload and lower rates of intubation and myocardial infarction.
Does high dose IV bolus of nitroglycerin lower rates of ICU admission compared to starting an infusion?
A retrospective observation cohort study of all patients treated in a large urban academic teaching center over the age of 18 who were given the final diagnosis in the ED charts of Acute Heart Failure AND were given nitroglycerin between January 1 2007 and July 31 2011. Patients were excluded if the nitroglycerin was ordered, but no given in the ED, if the patient was pregnant, or received nitroglycerin for another documented reason. Patients were then separated into 1 of 3 groups based upon the administration technique: Bolus, Drip, or combined.
– Bolus: Pushes of 1 to 2 mg of IV nitroglycerin Q5 minutes
– Drip: Continuous IV infusion rate set between 5-400micrograms
– Combo: 1 or more bolus followed by infusion
The analysis of the data showed that there was a significant reduction in ICU admissions for the bolus group compared to the other groups: Bolus(48%) vs Continuous (68%) vs Combo (83%). There was also a significant decrease in overall length of stay: Bolus (3.7) vs Infusion (4.7) and Combo (5.0). As for secondary outcomes there appeared to be no change in outcomes such as Intubation rates, NIPPV, hypotension, MI, or acute kidney injury.
Higher dose Nitroglycerin in bolus formation can be used to initially manage symptoms of acute heart failure with hypertension as a way to reduce ICU admission and hospital length of stay with no differences in secondary outcomes such as rate of intubation, bipap use, MI, acute kidney injury, or hypotension.