CMAJ • July 17, 2007; 177 (2). doi:10.1503/cmaj.1070054.
© 2007 Canadian Medical Association or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters

Acute decompensated heart failure

Howard A. Smithline, MD MS

Department of Emergency Medicine, Baystate Medical Center, Springfield, Mass.

I read with interest the review article on the management of acute decompensated heart failure by Larry Allen and Christopher O'Connor.1 The authors commented that nitroglycerin is probably underused in patients presenting with acute decompensated heart failure. However, in Table 1, in which they recommend switching from sublingual to intravenous delivery of nitroglycerin, the dose they suggest for initiating intravenous delivery seems low. A sublingual regimen of 0.4 mg every 5 minutes (the typical dose at my institution) is mathematically equivalent to 80 µg/min.

The bioavailability of sublingual nitroglycerin is cited in a 1998 study as 38%,2 but it can be highly variable.3 In many patients the tablets appear to be absorbed quickly and completely, but not infrequently one finds a tablet that remains undissolved after 5 minutes. In the latter circumstance, a lower dose of intravenous nitroglycerin, such as that recommended by the authors, would be suitable. In patients with marked hypertension not responding to completely dissolved sublingual nitroglycerin, a higher starting dose may be more appropriate.

Footnotes

Competing interests: None declared


REFERENCES

  1. Allen LA, O'Connor CM. Management of acute decompensated heart failure. CMAJ 2007;176(6):797-805.[Abstract/Free Full Text]
  2. Kirsten R, Nelson K, Kirsten D, et al. Clinical pharmacokinetics of vasodilators. Part II. Clin Pharmacokinet 1998;35(1):9-36.[CrossRef][Medline]
  3. Noonan PK, Benet LZ. Incomplete and delayed bioavailability of sublingual nitroglycerin. Am J Cardiol 1985;55(1):184-7.[CrossRef][Medline]




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