Is there a European study demonstrating renal protection with intravenous (IV) nitroglycerin (glyceryl trinitrate)?

From the Guidelines

There is no recent, high-quality European study demonstrating renal protection with intravenous (IV) nitroglycerin (glyceryl trinitrate) that directly addresses this outcome. The provided evidence primarily focuses on the use of IV nitroglycerin in the context of acute heart failure (AHF) and its vasodilatory effects, rather than specifically on renal protection 1. The 2008 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure discuss the use of nitrates, including IV nitroglycerine, in AHF, highlighting their venodilator effect and the recommendation for their administration in the early phase of AHF 1. However, these guidelines do not specifically address renal protection as an outcome.

Key points to consider when administering IV nitroglycerin include:

• The initial recommended dose is 10–20 mg/min, increased in increments of 5–10 mg/min every 3–5 min as needed 1.
• Slow titration and frequent blood pressure measurement are recommended to avoid large drops in systolic blood pressure (SBP) 1.
• The potential for tachyphylaxis and the need for close monitoring of blood pressure are important considerations when using IV nitroglycerin 1.

Given the lack of direct evidence on renal protection with IV nitroglycerin from recent, high-quality European studies, the decision to use IV nitroglycerin should be based on its established benefits in AHF and careful consideration of the patient's overall clinical context, including the potential for renal effects. It is crucial to prioritize the patient's morbidity, mortality, and quality of life when making treatment decisions, even in the absence of specific evidence on renal protection 1.

From the Research

Renal Protection with Intravenous Nitroglycerin

• There is evidence suggesting that intravenous nitroglycerin may have renal protective effects in certain patient populations, such as those with acute heart failure 2.
• A study comparing the effects of nesiritide and nitroglycerin on renal function in patients with acute heart failure found that nitroglycerin was associated with a decline in glomerular filtration rate and an increase in blood urea nitrogen, despite higher baseline and on-treatment blood pressures 2.
• Another study examining the use of intravenous nitroglycerin in the prehospital setting and emergency department for patients with acute heart failure found that early administration of nitroglycerin was associated with lower mortality and post-discharge events 3.
• However, it is essential to note that the evidence is not uniformly supportive of renal protection with intravenous nitroglycerin, and further studies are needed to fully understand its effects on renal function 2, 3.

Comparison with Other Agents

• Intravenous clevidipine, a calcium channel antagonist, has been shown to be effective in reducing blood pressure in patients with acute hypertension, with a safety profile similar to that of nitroglycerin and other agents 4.
• Clevidipine has been found to have a more rapid onset and shorter duration of action compared to nitroglycerin, making it a potentially useful alternative in certain clinical settings 4.

European Studies

• While the provided studies do not specifically focus on European populations, they do offer insights into the potential renal protective effects of intravenous nitroglycerin in patients with acute heart failure and other conditions 2, 3.
• Further research is needed to confirm these findings and to fully understand the effects of intravenous nitroglycerin on renal function in diverse patient populations, including those in European settings.