Revisiting vasodilator strategy in sympathetic crashing acute pulmonary edema: A meta-analysis of high-dose nitroglycerin efficacy and safety
In brief
High-dose nitroglycerin raises hypotension risk without clear ICU or intubation benefit
Across six studies with 534 patients in comparative analyses, high-dose intravenous nitroglycerin did not clearly reduce intubation or ICU admission compared with lower doses, and hypotension was about 41% more likely. Although single-arm studies reported symptom resolution in 95% of patients, varied dosing and co-treatments limit how confidently these findings can guide practice.
- Journal
- The American journal of emergency medicine (Q1)
- Published
- 19 September 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Yana A Jandali, Raghad M Sabbahi, Lareen M Sabi, Talal S Alsharari, Abdulaziz M Muhanna, Rebal N Khayyat, et al.
- PMID
- 42784941
- DOI
- 10.1016/j.ajem.2026.09.014
Why clinicians should know about it
- Picked for Emergency Medicine (top studies of the week, 27 September 2026): High‑dose nitroglycerin in SCAPE, acute pulmonary edema therapy
- Picked for Critical Care and Intensive Care Medicine (top studies of the week, 27 September 2026): Meta‑analysis of high‑dose nitroglycerin in SCAPE
Abstract
AIM: To evaluate the efficacy and safety of high-dose intravenous nitroglycerin compared with conventional low-dose strategies in patients with SCAPE. METHODS: A comprehensive search of PubMed, Scopus, Web of Science, and Cochrane Library databases was performed from inception to March 2026. Eligible studies included randomized controlled trials (RCTs) and observational studies assessing high-dose NTG (≥100 μg/min or equivalent bolus regimens) in adult patients with SCAPE. RESULTS: Six studies (n = 534 in comparative analysis) were included. No significant differences were observed in intubation rates (RR 0.91; 95% CI, 0.11-7.73), intensive care unit (ICU) admission (RR 0.92; 95% CI, 0.81-1.05), or ICU length of stay (MD -31.29 h; 95% CI, -330.32 to 267.73). Notably, high-dose NTG showed numerically higher estimates of achieving the target systolic blood pressure reduction compared with low-dose NTG (RR 1.70; 95% CI, 0.36-8.10; p = 0.15). High-dose NTG was associated with a modest increase in hypotension risk (RR 1.41; 95% CI, 1.02-1.94). Single-arm analysis demonstrated high rates of symptom resolution (95%) and relatively low intubation (10%) and ICU admission (12%) rates. Subgroup analyses showed rapid improvements in blood pressure, respiratory rate (RR), and oxygenation. CONCLUSION: High-dose intravenous nitroglycerin provides rapid hemodynamic and symptomatic improvement in SCAPE. However, these benefits do not clearly translate into reductions in intubation or ICU utilization and are accompanied by a modest increase in hypotension risk. Interpretation is constrained by variable low-dose comparator definitions, differing high-dose regimens, and inconsistent reporting of co-interventions.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.