Sodium Nitroprusside for Treating Hospitalized Patients With Acute Heart Failure

20s male patient in hospital bed listening to doctor and nurse in hospital
Researchers sought to evaluate the safety and effectiveness of sodium nitroprusside plus standard therapy for treatment of acute heart failure.

In hospitalized patients with acute heart failure (HF), the vasodilator sodium nitroprusside is a safe, effective treatment when added to standard therapy, particularly in individuals with a dilated left ventricle, for achievement of rapid decongestion and hemodynamic improvement. These findings were published in the International Journal of Cardiology.

A multicenter, retrospective cohort study ( Identifier: NCT05027360) was conducted among patients consecutively admitted for acute HF at 2 Italian centers. Investigators sought to explore the effectiveness, as observed by reduction in N-terminal pro-B natriuretic peptide (NT-proBNP) values, and safety of treatment with sodium nitroprusside, to examine the impact of reduction in NT-proBNP levels on the short-term and mid-term clinical endpoints (overall mortality and hospitalization for HF) and to identify potential predictors of clinical response to sodium nitroprusside treatment.

The primary study endpoint was a 25% or higher reduction in NT-proBNP levels from baseline within 48 hours of sodium nitroprusside infusion initiation. Secondary and safety endpoints included all-cause mortality; rehospitalization for HF at 1 month, 3 months, and 6 months; length of stay (LOS) in hospital; and severe hypotension.

A total of 200 patients were enrolled in the study. Sodium nitroprusside infusion was initiated within 24 hours of hospital admission at a low dose (0.1-0.2 μg/kg/min) and titrated to a target mean arterial pressure of 65 to 75 mm Hg.  The median maximal sodium nitroprusside dose administered within the first 48 hours of infusion was 0.3 μg/kg/min (IQR, 0.2-0.5 μg/kg/min). Median duration of sodium nitroprusside infusion was 5 days (IQR, 4-8 days).

Results of the study showed that 66% of participants experienced a reduction in NT-proBNP values of 25% or higher within 48 hours of treatment onset, regardless of their initial systolic blood pressure. The only independent predictor of treatment efficacy was left ventricular end-diastolic diameter.

Those participants who attained the primary endpoint (“responders”) experienced a significantly lower LOS (median, 15 days [IQR, 10-27 days] vs 19 days [IQR, 12-35 days]; P =.033), as well as a significantly lower incidence of all-cause mortality and rehospitalization for HF at 1 month and 5 months, compared with the “nonresponders” (P <.050). Severe hypotension was reported in 5% of the participants, without any adverse clinical outcomes.

Some key limitations of the study include that it is a retrospective, observational study without a control group. Additionally, limitations associated with the use of a surrogate endpoint (changes in NT-proBNP changes) in the area of acute HF are well known, with many randomized clinical trials not reporting a relationship between a decrease in natriuretic peptides and long-term mortality.

“When added to standard treatment regimen of hospitalized patients with [acute] HF, [sodium nitroprusside] is safe and effective in achieving rapid decongestion and hemodynamic improvement,” the study authors wrote.

Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Garatti L, Frea S, Bocchino PP, et al. Sodium nitroprusside in acute heart failure: a multicenter historic cohort study. Int J Cardiol. Published online August 6, 2022.