Nitroglycerin Infusion in Old Inferior Wall MI

Critical Risk Assessment Before Administration

The American College of Cardiology recommends that patients with inferior MI and RV involvement are critically dependent on adequate right ventricular preload to maintain cardiac output and can experience profound hypotension during nitrate administration, particularly in the context of old inferior wall MI 1, 2, 3
Baseline blood pressure must be ≥90 mmHg systolic; nitroglycerin is contraindicated if SBP <90 mmHg or ≥30 mmHg below baseline, as stated by the American College of Cardiology 1, 4

The American College of Cardiology suggests that control of clinical symptoms, such as pain and heart failure, is a key endpoint for titration 1
Decrease mean arterial pressure by 10% in normotensive patients or 30% in hypertensive patients, as recommended by the American College of Cardiology 1, 6
Never allow systolic blood pressure to fall below 90 mmHg, according to the American College of Cardiology guidelines 1, 6

The American College of Cardiology advises that if hypotension develops during nitroglycerin infusion, immediately discontinue nitroglycerin 1, 6, 7
Elevate legs to increase venous return and administer rapid IV fluid bolus, as recommended by the American College of Cardiology 1, 6, 7

The American College of Cardiology notes that in chronic/old MI, the hemodynamic vulnerability is substantially reduced unless there is residual RV dysfunction or ongoing ischemia 1
Doses >200 mcg/min are associated with increased hypotension risk; consider alternative vasodilator, such as a calcium channel blocker, at this point, as suggested by the American College of Cardiology 1, 2