Article Text

Download PDFPDF
High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial
  1. Naazia Siddiqua1,
  2. Roshan Mathew1,2,
  3. Ankit Kumar Sahu1,
  4. Nayer Jamshed1,
  5. Jyothiswaroop Bhaskararayuni1,
  6. Praveen Aggarwal1,
  7. Akshay Kumar1,
  8. Maroof Ahmad Khan3
  1. 1 Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
  2. 2 Emergency Medicine, Hamdard Institute of Medical Science and Research, New Delhi, India
  3. 3 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
  1. Correspondence to Dr Nayer Jamshed, Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India; jamshednayer{at}


Objectives Sympathetic crashing acute pulmonary edema (SCAPE) is a subset of heart failure with a dramatic presentation. The unique physiology of this condition requires a different management strategy from the conventional practice. The trial objective was to compare the efficacy of high-dose and low-dose GTN in patients with SCAPE.

Methods This was an open-label randomised control trial conducted in a tertiary care teaching hospital in India from 11 November 2021 to 30 November 2022. Consenting participants were randomised to high-dose GTN or conventional low-dose GTN. The primary outcome was symptom resolution at 6 hours and 12 hours. Secondary outcomes included intubation rates, admission rates, length of hospital stay, and any short-term adverse effects of GTN and major adverse cardiac events (MACE) at 30 days.

Results Fifty-four participants were included (26 high-dose GTN, 26 low-dose GTN). At 6 hours, symptom resolution was seen in 17 patients (65.4%) in the 'high-dose' group, compared with 3 (11.5%) in the 'low-dose' group (p<0.001). At 12 hours, 88.5% of patients had a clinical resolution in the 'high-dose' arm versus 19.5% in 'low-dose' arm . The low-dose group had longer median hospital stay (12 hours vs 72 hours), more frequent MACE (3.8% vs 26.9%, p=0.02) and a higher intubation rate (3.8% vs 19.2%, p=0.08). The only short-term adverse effect seen was a headache in both the groups.

Conclusion In SCAPE, patients receiving high-dose GTN (>100 mcg/min) had earlier symptom resolution compared with the conventional ‘low dose’ GTN without any significant adverse effects.

Trial registration Clinical trial registry of India (CTRI/2021/11/037902).

  • heart failure
  • resuscitation

Data availability statement

Data are available upon reasonable request.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

Data are available upon reasonable request.

View Full Text


  • NS and RM are joint first authors.

  • Handling editor Richard Body

  • Twitter @NaaziaSiddiqua, @roshmat15, @jswaroop007

  • NS and RM contributed equally.

  • Contributors NJ, RM, PA, MAK: conceptualisation, methodology. NS, RM, AKS, JB: recruitment, data curation, writing, original draft preparation. NJ, AKS, PA, AK: supervision. AKS, MAK: software validation. RM, AKS, NS, AK: writing, reviewing and editing. NJ takes full responsibility for the conduct of the study, has access to the data, and controlled the decision to publish.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.