Nitroprusside for acutely decompensated congestive heart failure and lactacidemia: a single-center experience

Cardiogenic shock continues to carry a high mortality rate despite advances in pathophysiological understanding and mechanical circulatory support (1). Due to heterogeneous phenotypes and frequent multi-organ dysfunction, individualized therapeutic strategies remain essential, and universally accepted guidelines are lacking.

To assess the safety and efficacy of sodium nitroprusside in patients with congestive heart failure and biochemical evidence of hypoperfusion (elevated lactate) despite preserved mean arterial pressure (MAP >65 mmHg).

This single-center, retrospective study included 14 critically ill patients treated in the Cardiac Intensive Care Unit between March 2022 and September 2025. Nitroprusside was administered and titrated to maintain a target MAP ≥55 mmHg. All patients had invasive arterial pressure monitoring, and hemodynamic assessment was primarily echocardiographic. Outcomes included changes in lactate and creatinine levels, 30-day survival, and adverse events.

The analysis included 14 patients with elevated lactate levels, all were clinically assessed as congested. The mean age was 62±13 years; 12 patients (85.7%) had biventricular heart failure, while 8 out of 14 patients (57.1%) had non-ischemic dilated cardiomyopathy, and only one patient had cardiogenic shock secondary to acute coronary syndrome, while all others had acute decompensation of chronic heart failure. One patient was treated with both nitroprusside and axial flow pump, while one patient received treatment with extracorporeal membrane oxygenation. Ten patients (71.4%) in addition to nitroprusside were also on low-dose inotropic support. The initial mean lactate level was 4.7 mmol/L (IQR 4–7.27), followed by a statistically significant decrease after 24 hours (2.19, IQR 1.1–4.05, p=0.003), 48 hours (1.09, IQR 0.86–1.5, p=0.001), and 72 hours (1.28, IQR 0.79–1.69, p=0.001). Serum creatinine also decreased significantly after seven days (149.64±45.89 µmol/L vs. 111.91±47.75 µmol/L, p=0.01). The 30-day survival rate was 71.4%. Among survivors, two underwent heart transplantation without the need for mechanical circulatory support as a bridge to transplant, while nine (60%) were stabilized and discharged home. The mean duration of nitroprusside infusion was 43.46±24.4 hours, with no nitroprusside-related adverse events observed.

Nitroprusside therapy was associated with rapid decongestion, improved tissue perfusion, and recovery of target organ function. Despite the small sample size and single-center design, these results suggest that controlled afterload reduction with nitroprusside may represent a valuable therapeutic option for hemodynamic stabilization in selected patients with advanced heart failure and preserved mean arterial pressure potentially postponing or minimizing the requirement for mechanical circulatory support in selected cardiogenic shock patients (2).