EBM Consult

Sublingual Nitroglycerin for Acute Decompensated Heart Failure (HF) with Hypertension


  • Patients presenting with acute decompensated heart failure (HF) and flash pulmonary edema due to acute increases in blood pressure can be in severe respiratory distress. 
  • Assuming the patient does not have aortic stenosis or an inferior myocardial infarction, and did not use a type 5 phosphodiesterase inhibitor (e.g., sildenafil) within the last 24-48 hours, the patient can be given sublingual (SL) nitroglycerin (NTG) for the purposes of reducing blood pressure, end-diastolic volumes and afterload, while also improving cardiac output or forward flow. The combined result of these multiple effects is to improve the pulmonary edema and respiratory distress.   
  •  This is especially effective if used in conjunction with early initiation of Bilevel Positive Airway Pressure ventilation (BiPAP), and can be used to temporize while the patient is getting IV access, through which an infusion of nitroglycerin can be started

How to Use Sublingual Nitroglycerin & Rationale:

  • Standard SL NTG tablets or sprays most commonly come as 0.4 mg (or 400 mcg) per tablet or spray and are given every 3 to 5 minutes up to 3 doses. The onset of action is ~ 1 min and peaks at ~ 5 minutes.
  • This means each tablet or spray of NTG provides about 80 - 130 mcg/min of NTG.
  • Studies have shown that patients can receive doses as high as 400 - 800 mcg as an IV bolus over 1 to 2 minutes.  After the bolus, many patients can be started on 100 mcg/min and titrated to clinical effect. 
  • Therefore, giving 1 to 2 doses of SL NTG can provide similar results, buying you time until IV access is obtained for an infusion to be started. 
  • Assuming that the airway is intact and the patient can follow basic commands, start BiPAP (starting at inspiratory pressure of 10 and expiratory pressure of 5; i.e., "10 over 5").  BiPAP can not only improve the pulmonary edema by pushing that fluid back into circulation, but also aids in oxygenation and ventilation due to improved alveolar recruitment, while reducing the risk of needing intubation.  (Note: Excessive pressures from BiPAP can also increase intrathoracic pressure and thereby reduce preload. This, in addition to the reductions in preload from SL NTG, can eventually reduce cardiac output and cause severe hypotension.)
  • Many patients will show signs of improvement within 10 minutes of these 2 interventions alone.

  Anthony J. Busti, MD, PharmD, FNLA, FAHA
Dylan Kellogg, MD
Last Reviewed:
  August 2015

Original Studies

  • Haude M, et al. Sublingual administration of captopril versus nitroglycerin in patients with severe congestive heart failure. Int J Cardiol 1990;27(3):351-9. PubMed
  • Mikulic E, et al. Comparative hemodynamic effects of chewable isosorbide dinitrate and nitroglycerin in patients with congestive heart failure. Circulation 1975;52(3):477-82. PubMed
  • Bussman WD, et al. Effect of sublingual nitroglycerin in emergency treatment of severe pulmonary edema. Am J Cardiol 1978;41(5):931-936. PubMed

Supporting Studies

  • Marmor A, et al. Comparative evaluation of a new formulation of isosorbide dinitrate oral spray and sublingual nitroglycerin tablets. Am J Cardiol 1990;65(21):43J-45J. PubMed
  • Willis WH Jr, et al. Hemodynamic effects of isosorbide dinitrate vs nitroglycerin in patients with unstable angina. Chest 1976;69(1):15-22. PubMed

Review Articles

  • Elkayam U et al. Comparison of effects on left ventricular filling pressure of intravenous nesiritide and high-dose nitroglycerin in patients with decompensated heart failure. Am J Cardiol 2004;93(2):237-40. PubMed
  • Bersten AD et al. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med 1991;325:1825-1830.

Related Content

YouTube Lectures

  • High-Yield Med Reviews publishes their Rapid Reviews by Anthony Busti, MD, PharmD occasionally that relate to EBM Consult topics and that provide evidence-based answers to clinically relevant questions that relate to every day clinical practice.  

    • Lecture:  How can giving a patient nitroglycerin who is also taking a drug like Viagra cause severe hypotension or cardiogenic shock?


    • Lecture:  Why do clinicians always give furosemide (Lasix) IV instead of by mouth for acute heart failure?


    • Lecture: Can you give a patient with a reported "sulfa allergy" furosemide (Lasix)?



  • Acute Decompensated Heart Failure, Acute CHF, Acute HF, Sublingual Nitroglycerin