II. Indications
- Acute Myocardial Ischemia (Angina Pectoris)
- Acute Myocardial Infarction
- Limits infarct expansion
- Reduces infarct size
- Inferior wall Myocardial Infarction
- Congestive Heart Failure associated with infarction
- Decreases vasospasm at site of Plaque rupture
- Congestive Heart Failure with Acute Pulmonary Edema
-
Hypertensive Emergency
- Specifically indicated for Hypertensive Emergency with Acute Pulmonary Edema
- Nicardipine (or Esmolol) are indicated as first line agents in most other cases of Hypertensive Emergency
III. Contraindications
- See Nitroglycerin
IV. Preparation
- Mix 50 mg Nitroglycerin in 250 ml D5W (200 mcg/ml)
V. Pharmacokinetics
- Onset in 2 minutes
- Duration 3 to 5 minutes
- Expect Blood Pressure to drop within 3 to 5 minutes of infusion start
- Effects wane within 3 to 5 minutes of stopping infusion
-
Nitroglycerin is absorbed by polvinyl chloride (PVC) IV tubing, and therefore dosing is increased to compensate for this loss
- Use lower doses when non-PVC IV tubing is used
VI. Dosing: Acute Myocardial Ischemia or Infarction (Adults)
- Bolus: 12.5 to 25 mcg Nitroglycerin IV
- Consider bolus if Sublingual Nitroglycerin has not yet been given
- Tittration to maintenance dose
- Start: 10 to 20 mcg/min (3-6 ml/hour)
- Titrate: Increase 5 to 10 mcg/min every 5 minutes
- Usual dosage: 50 to 200 mcg/min (maximum 500 mcg/min)
- Endpoints
- Blood Pressure drop over 10%
- Adequate decrease in Systemic Vascular Resistance
- Adequate fall in left ventricular filling pressure
- Relief of Chest Pain
VII. Dosing: Hypertensive Emergency (Adults)
- Start
- Consider rapid large bolus of 400 mcg/min for 2 minutes OR
- Start 10 to 20 mcg/min and titrate to 100 mcg/min
- Next
- Decrease dose to 100 to 150 mcg/minute
- Observe for effect and be ready to decrease dose
- Cummulative bolus dose in Hypertensive Emergency approaches 400 mcg over 5 minutes
VIII. Dosing: Children (Not FDA Approved)
- Start 0.25 to 0.5 mcg/kg/min
- Increase by 0.5 to 1 mcg/kg/min every 3 to 5 min as needed
- Maximum 5 mcg/kg/min
IX. Adverse Effects
- See Nitroglycerin
X. Mechanism
- See Nitroglycerin
XI. Safety
- Pregnancy Category C
- Unknown safety in Lactation
XII. Adverse Effects
- See Nitroglycerin
XIII. Safety
- Pregnancy Category C
- Unknown Safety in Lactation
XIV. Resources
- Nitroglycerin Infusion (Dailymed)
XV. References
- Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 70-1
- Hamilton (2020) Tarascon Pocket Pharmacopoeia