HIGH-DOSE nitroglycerin provided rapid haemodynamic and symptomatic improvement in patients with sympathetic crashing acute pulmonary oedema, although these benefits did not significantly reduce intubation or intensive care unit admission rates. The analysis also identified a modest increase in hypotension risk with high-dose treatment.
Researchers evaluated the efficacy and safety of high-dose intravenous nitroglycerin (NTG) compared with conventional low-dose strategies in adults with sympathetic crashing acute pulmonary oedema (SCAPE).
PubMed, Scopus, Web of Science, and Cochrane Library were searched from inception to March 2026. Eligible studies included randomised controlled trials and observational studies assessing high-dose NTG, defined as ≥100 μg/min or equivalent bolus regimens.
Six studies were included, with 534 patients contributing to the comparative analysis.
No significant differences were observed between high-dose and low-dose NTG with regard to intubation rates (risk ratio [RR]: 0.91; 95% CI: 0.11–7.73) or intensive care unit admission (RR: 0.92; 95% CI: 0.81–1.05).
Similarly, intensive care unit length of stay did not differ significantly (mean difference: −31.29 hours; 95% CI: −330.32–267.73).
High-dose NTG produced numerically higher estimates for achieving the target systolic blood pressure reduction compared with low-dose treatment, although the difference was not statistically significant (RR: 1.70; 95% CI: 0.36–8.10; p=0.15). Subgroup analyses also showed rapid improvements in blood pressure, respiratory rate, and oxygenation.
High-dose NTG was associated with a modest increase in hypotension risk (RR: 1.41; 95% CI: 1.02–1.94). In single-arm analyses, symptom resolution reached 95%, while intubation and intensive care unit admission rates were 10% and 12%, respectively.
Despite rapid haemodynamic and symptomatic improvements, the findings did not demonstrate clear reductions in intubation or intensive care utilisation. Interpretation was limited by variations in low-dose comparator definitions, differences between high-dose regimens, and inconsistent reporting of co-interventions.
Reference
Jandali YA et al. Revisiting vasodilator strategy in sympathetic crashing acute pulmonary edema: A meta-analysis of high-dose nitroglycerin efficacy and safety. Am J Emerg Med. 2026. https://doi.org/10.1016/j.ajem.2026.09.014
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