Abstract
Purpose of Review Nitrates represent a frequently used group of medications in the management of hypertensive patients in acute heart failure. Despite its longevity, usage of this medication seems to be guided chiefly by expert opinion, with relatively few trials involving interventions in the emergency department. This review seeks to define more precisely the role of nitrates in the emergency department by discussing some of the more compelling research that exists on the topic in addition to their biochemistry and current guidelines.
Recent Findings More recent explorations have demonstrated various benefits to regimens of high dose nitrates started in the emergency department such as lower rates of ICU admission and endotracheal intubation. The more feared complications of nitrate use, namely hypotension, do not see an increase in incidence with increase in dosages.
Summary High-quality trials that demonstrate either optimal dosage of nitrates and even explicit hemodynamic or mortality benefits associated with their use still eludes us. Current recommendations and expert opinion continue to guide therapy while evidence that does exist suggests possible equivalency of high dose intermittent administration to titratable infusion. As nitrates have long been a cornerstone in the management of pulmonary congestion in acute heart failure, a true double-blinded RCT to demonstrate their benefits may not be practical. In light of this, current evidence suggests that future research on dosage and route of administration may help to minimize cost associated with hospitalization (e.g., ETT, ICU admissions, drips).