Role of high-dose intravenous nitrates in hypertensive acute heart failure

Am J Emerg Med. 2020 Jan;38(1):132-137. doi: 10.1016/j.ajem.2019.06.046. Epub 2019 Jun 25.


Background: Patients with hypertensive acute heart failure (H-AHF) can decompensate rapidly and require immediate medical attention; the use of high-dose nitroglycerin is a topic of growing interest in this patient population.

Objective of the review: The purpose of this review is to provide an evidence-based approach for the utilization of high-dose nitrates in the emergent management of H-AHF.

Discussion: Two randomized controlled trials, three prospective studies, two retrospective cohorts, two case series, and one case report were evaluated. Level of robust evidence and heterogeneity limit the ability to draw strong conclusions regarding the use of high-dose nitrates. Despite these limitations, high-dose nitrates appeared to have an overall beneficial effect across all studies reviewed, including lower rates of mechanical ventilation, improvement in blood pressure, shorter LOS, and lower rates of ICU admission. Adverse effects were mild and infrequently reported.

Conclusions: High-dose nitrates are likely safe and may be effective, as demonstrated in the studies reviewed. High-dose NTG may be appropriate in H-AHF patients presenting with severe respiratory distress and SBP ≥160 mmHg or MAP ≥120 mmHg. Future well-designed randomized controlled trials are needed to elucidate optimal dosing strategies and confirm safety and efficacy of high-dose nitrates.

Keywords: Bolus-dose nitroglycerin; High-dose nitroglycerin; Hypertensive acute heart failure; Nitrates; Nitroglycerin; Pulmonary edema.

Publication types

  • Review

MeSH terms

  • Emergency Service, Hospital
  • Heart Failure / drug therapy*
  • Heart Failure / physiopathology
  • Humans
  • Hypertension / complications*
  • Hypertension / physiopathology
  • Infusions, Intravenous
  • Nitroglycerin / administration & dosage*
  • Vasodilator Agents / administration & dosage*


  • Vasodilator Agents
  • Nitroglycerin