High-Dose Nitroglycerin for Sympathetic Crashing Acute Pulmonary Edema

Sympathetic crashing acute pulmonary edema (SCAPE), formerly known as flash pulmonary edema, is an extreme complication of heart failure. In SCAPE, left ventricular dysfunction results in a surge of adrenergic activity and increased left atrial pressure. This causes distension of the pulmonary capillaries, interstitial edema, and flooding of the alveolar spaces, ultimately resulting in hypoxia. Identifying SCAPE can be challenging due to a lack of universally accepted diagnostic criteria; however, patients often present with a sudden onset of severe dyspnea, life-threatening pulmonary congestion, and high systolic blood pressure. Clinical guidelines recommend the use of noninvasive positive pressure ventilation and intravenous (IV) nitroglycerin in patients with acute heart failure syndrome and dyspnea. Timely initiation of these therapies is essential to prevent the need for intubation and invasive mechanical ventilation. Due to limited available data, there is wide variability in the administration and dosing of high-dose nitroglycerin (HDN) for patients with SCAPE.