Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure

Objectives

The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both.

Methods

We retrospectively identified 395 patients that received nitroglycerin therapy in the ED for the treatment of AHF over a 5-year period. Patients that received intermittent bolus (n = 124) were compared with continuous infusion therapy (n = 182) and combination therapy of bolus and infusion (n = 89). The primary outcomes were the frequency of intensive care unit (ICU) admission and hospital length of stay (LOS).

Results

On unadjusted analysis, rates of ICU admission were significantly lower in the bolus vs infusion and combination groups (48.4% vs 68.7% vs 83%, respectively; P < .0001) and median LOS (interquartile range) was shorter (3.7 2.5-6.2 days]) compared with infusion (4.7 2.9-7.1 days]) and combination (5.0 2.9-6.7 days]) groups; P = .02. On adjusted regression models, the strong association between bolus nitroglycerin and reduced ICU admission rate remained, and hospital LOS was 1.9 days shorter compared with infusion therapy alone. Use of intubation (bolus 8.9%] vs infusion 8.8%] vs combination 16.9%]; P = .096) and bilevel positive airway pressure (bolus 26.6%] vs infusion 20.3%] vs combination 29.2%]; P = .21) were similar as was the incidence of hypotension, myocardial injury, and worsening renal function.

Conclusions

In ED patients with AHF, intravenous nitroglycerin by intermittent bolus was associated with a lower ICU admission rate and a shorter hospital LOS compared with continuous infusion.