(195) Emergent Therapy for Sympathetic Crashing Acute Pulmonary Edema With High-Dose Nitroglycerin

Introduction: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is a life-threatening complication in patients with heart failure. The management of SCAPE primarily focuses on respiratory support with non-invasive ventilation and afterload reduction, necessitating the need for high-dose nitroglycerin (HDN) infusions . The purpose of this study is to determine the timing of SCAPE resolution due to HDN for patients in the emergency department of a large academic medical center and to determine optimal dosing strategies while mitigating risks associated with SCAPE and HDN.

Methods: This retrospective, descriptive, cross-sectional study included adult patients ≥18 years old who were prescribed nitroglycerin (NTG) infusion that reached rates ≥100 mcg/min in the emergency department (ED) between January 1, 2019 and January 31, 2023. Patients were included if they had an initial systolic blood pressure (SBP) ≥160 mmHg and respiratory distress noted by an ED physician. Patients who were pregnant or were incarcerated were excluded from this study. Primary outcome measure was median time to normalization of blood pressure based on the NTG infusion order. Secondary outcomes included incidence of unfavorable outcomes, median patient hospital length of stay, and median ED length of stay.

Results: A total of 236 patients were screened from January 1, 2019 to January 31, 2023. Of those patients, 61 patients were included in the study and analyzed. The median time to SCAPE resolution based on blood pressure parameters set by the nitroglycerin infusion orders was 116 minutes. The incidence of reported adverse effects were hypotension 13.1% (8/61), headache 8.2% (5/61), endotracheal intubation 8.2% (5/61), and syncope 3.3% (2/61). The median ED length of stay was 9.4 hours and median hospital length of stay was 3.2 days.

Conclusions: The use of high dose nitroglycerin was demonstrated to be safe and led to the successful resolution of SCAPE. Additional studies are needed to determine appropriate dosing strategies for high dose nitroglycerin’s role in SCAPE.