Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure.
OBJECTIVE
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.
Department of Pharmacy Services, Detroit Receiving Hospital/Detroit Medical Center, Detroit, MI 48201.
Suprat Saely
SS
Wilson
Department of Pharmacy Services, Detroit Receiving Hospital/Detroit Medical Center, Detroit, MI 48201.
Gregory M
GM
Kwiatkowski
Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, MI 48201.
Scott R
SR
Millis
Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, MI 48201.
John D
JD
Purakal
Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, MI 48201.
Arushi P
AP
Mahajan
Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, MI 48201. Electronic address: plevy@med.wayne.edu.
Phillip D
PD
Levy
D000208:Acute Disease; D000328:Adult; D000368:Aged; D004636:Emergency Service, Hospital; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000209:etiology; D006760:Hospitalization; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy*; D007262:Infusions, Intravenous; D007275:Injections, Intravenous; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D005996:Nitroglycerin / Q000008:administration & dosage*; D012189:Retrospective Studies; D014665:Vasodilator Agents / Q000008:administration & dosage*
D014665:Vasodilator Agents; D005996:Nitroglycerin