Category: Pharmacology & Therapeutics
Posted: 12/9/2025 by Ashley Martinelli
(Updated: 12/11/2025)
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Sympathetic crashing acute pulmonary edema (SCAPE) is an acute, aggressive pulmonary edema that occurs in patients with hypertensive emergencies. Nitroglycerin (NTG) is often utilized in combination with non-invasive positive pressure ventilation to prevent decompensation; however, data is lacking regarding the optimal dosing strategy.
Study design: retrospective, single-center, cohort study at an academic medical center
Inclusion: adult patients with a primary or secondary diagnosis of pulmonary edema, acute heart failure exacerbation, hypertensive emergency, or hypertensive crisis and were initiated on NTG in the ED.
Exclusion: hypertensive emergency with different BP goals (dissection, eclampsia, ICH)
Study groups: based on initial NTG dose (<100 mcg/min = low dose, ? 100 mcg/min = high dose)
Primary outcome: time from NTG initiation to oxygen weaning (removal of necessary oxygen back to baseline or home oxygen
Baseline: 61 years old, 50% male, 97% with history of hypertension, 84% history of heart failure, and 36% with ESRD. A higher percentage of patients in the high dose group has CPAP/BIPAP (49% vs 27% p<0.001)
Results: High dose NTG group had a shorter time from NTG to oxygen wean of 2.67h compared to 3.28 hours in the low group. The high dose group also was more likely to achieve goal SBP reduction of 25% within the hour (55% v 34%, p<0.001) had a shorter duration of NTG infusion overall 4.9h vs 6.9h, p0.033) and had decreased ICU LOS by 0.5 days. There were more cases of hypotension in the high dose group which was primarily driven by acute drops in SBP >30%.
Bottom Line: Consider using NTG 100 mcg/min initially to manage patients with SCAPE in the ED.
Henry K, Pelsue B, Hartman H, Gulbis B. Low versus high dosing strategies of intravenous nitroglycerin for the management of sympathetic crashing acute pulmonary edema. Am J Emerg Med. 2025; 98:41-45.
