In a patient with sympathetic‑crisis acute pulmonary edema (SCAPE) presenting with severe hypertension and tachycardia, what is the first‑line treatment for the hypertensive emergency?

First-Line Treatment for SCAPE (Sympathetic Crashing Acute Pulmonary Edema)

High-dose intravenous nitroglycerin combined with non-invasive positive pressure ventilation (NIPPV) is the first-line treatment for SCAPE presenting with severe hypertension and tachycardia. 1, 2

Immediate Concurrent Management

Respiratory Support

• Initiate NIPPV immediately with oxygen supplementation to maintain oxygenation, as this is associated with reduced need for intubation, improved survival, and improved respiratory indices in SCAPE patients 2
• NIPPV should be started concurrently with vasodilator therapy, not sequentially 1

First-Line Vasodilator: High-Dose Nitroglycerin

Dosing Protocol:

• Start with high-dose bolus nitroglycerin rather than traditional low-dose titration 2, 3
• Initial bolus dosing can range from 1-9 mg IV depending on severity, followed immediately by infusion 3
• Infusion starting dose: 100-200 mcg/min (not the traditional 10-20 mcg/min used for preload reduction) 3, 4
• Titrate upward rapidly every 3-5 minutes by 15-30 mcg/min increments until blood pressure control is achieved 4
• Doses exceeding 100 mcg/min provide arterial dilation and afterload reduction, which is the primary therapeutic goal in SCAPE 3

Rationale:

• The central pathophysiological feature of SCAPE is pathologically elevated afterload due to systemic vasoconstriction, not volume overload 3
• SCAPE patients may be euvolemic, hypovolemic, or hypervolemic—the problem is fluid shift into the lungs rather than total body hypervolemia 3
• High-dose nitroglycerin (>100 mcg/min) causes afterload reduction through arterial dilation, breaking the vicious cycle of sympathetic surge 3

Second-Line Agents for Refractory Hypertension

If blood pressure remains refractory to NIPPV plus high-dose nitroglycerin:

• Nicardipine IV is the preferred second-line agent 5, 2

  • Start at 5 mg/hr, titrate by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr 6
  • Nicardipine is particularly effective when nitroglycerin resistance or attenuated response occurs 5
  • Addition of nicardipine can lead to marked clinical improvement and spare patients from intubation 5

• Clevidipine is an acceptable alternative 2

  • Start at 1-2 mg/hr, double every 90 seconds until blood pressure approaches target 6

What NOT to Do in SCAPE

Avoid routine diuretic administration:

• Diuretics should NOT be routinely administered in SCAPE patients in the absence of systemic volume overload 2
• Only give diuretics if clear evidence of fluid overload exists (cardiomegaly, peripheral edema, documented weight gain) 2
• The emphasis in treating SCAPE has shifted from diuretics to vasodilators 3

Exercise caution with:

• Opioids – use with caution in SCAPE patients 2
• Beta-blockers – use with caution in SCAPE patients 2
• ACE inhibitors (enalaprilat) – only an option in those with normal renal function and resistant hypertension 2

Blood Pressure Targets

• Reduce mean arterial pressure by 20-25% within the first hour 1, 7
• Target systolic blood pressure <140 mmHg immediately in acute cardiogenic pulmonary edema 7
• Then aim for <160/100 mmHg over 2-6 hours if stable 1
• Avoid excessive acute drops >70 mmHg systolic, which can precipitate organ ischemia 6

Monitoring Requirements

• Continuous blood pressure and heart rate monitoring throughout treatment 6
• Serial assessment of respiratory status and oxygenation 2
• Point-of-care ultrasound can rapidly confirm pulmonary edema (bilateral B-lines in all lung zones) 3

Critical Pitfalls to Avoid

• Do not start with traditional low-dose nitroglycerin (10-20 mcg/min) – this only provides preload reduction and is insufficient for SCAPE 3
• Do not reflexively give diuretics – SCAPE is primarily an afterload problem, not a volume problem 3
• Do not use sodium nitroprusside as first-line – nitroglycerin or nicardipine are preferred for acute pulmonary edema 1
• Do not delay NIPPV – respiratory support must be initiated immediately alongside vasodilator therapy 2