Treatment of Hypertensive Cardiogenic Edema with Intravenous High-Dose Nitroglycerin in a Patient Presenting with Signs of Respiratory Failure: A Case Report and Review of the Literature

Abstract

Patient: Male, 63Final Diagnosis: Hypertensive cardiovenic pulmonary edemaSymptoms: Shortness of breathMedication: —Clinical Procedure: —Specialty: General and Internal MedicineObjective:Management of emergency careBackground:Pulmonary edema is the accumulation of fluid in the lung secondary to increased hydrostatic pressure. Hypertensive cardiogenic pulmonary edema presents with a sudden onset of severe dyspnea, tachycardia, and tachypnea, and can occur when the systolic blood pressure exceeds 160 mmHg in association with acute decompensated congestive cardiac failure (CCF). A case is presented of hypertensive cardiogenic pulmonary edema treated with high-dose nitroglycerin and includes a review of the literature.Case Report:A 63-year-old Hispanic male with a medical history of hypertension, coronary artery disease, heart failure with a reduced ejection fraction of 35%, chronic kidney disease (CKD) and diabetes mellitus, presented as an emergency with acute, severe dyspnea. The patient was initially managed with 100% oxygen supplementation and intravenous (IV) high-dose nitroglycerin (30 mcg/min), which was titrated every 3 minutes, increasing by 15 mcg/min until a dose of 120 mcg/min was reached. After 18 minutes of aggressive therapy, the patient’s condition improved and he no longer required mechanical ventilation.Conclusions:Hypertensive cardiogenic pulmonary edema is a challenging clinical condition that should be diagnosed and managed as early as possible, and distinguished from respiratory failure due to other causes. Although hypertensive cardiogenic pulmonary edema is usually managed acutely with high-dose diuretics, this case has highlighted the benefit of high-dose IV nitroglycerin, and review of the literature supports this treatment approach.

Valvular Heart Disease Presenting as Sympathetic Crashing Acute Pulmonary Edema (SCAPE) Phenomenon: A Diagnostic and Management Paradigm

“…The presentation of SCAPE is a medical emergency that requires prompt diagnosis and adequate treatment [ 7 ]. In addition, immediate ED management of severe pulmonary edema decreases the rates of subsequent invasive mechanical ventilation and prolonged hospital stay [ 1 ].…”

Relationship between noninvasive central blood pressure and brain natriuretic peptide levels in patients with hypertensive pulmonary edema

“…Hypertensive pulmonary edema is the severest form of HTN-related HF, meanwhile, it is a reversible condition when managed properly [15]. Early clinical diagnosis is of utmost importance and should be done before the release of laboratory tests [1]. Inaccurate brachial BP measurement and interpretation in the emergency department was documented in the literature, which can be explained by excessive workload [16].…”

“…Hypertensive pulmonary edema is one of the hyperacute complications of hypertension (HTN) and represents 25% of heart failure (HF) admissions with reported mortality up to 20% [1,2]. Emerging evidence suggests that central pressure is more associated with future cardiovascular events than brachial pressure [3].…”

Clinical Review of Hypertensive Acute Heart Failure

“…In patients with H-AHF, cardiac decompensation usually occurs quickly, within a few hours to a few days [25,42,43]. Often the only precipitating factor for AHF is arterial hypertension.…”