Hospital Pharmacy - July/August 2017 - 502

722538
research-article2017

HPXXXX10.1177/0018578717722538Hospital PharmacyGibson et al.

Article

Examining the Use of Sodium
Nitroprusside in Coronary Artery
Bypass Grafting: Is the Benefit
Worth the Cost?

Hospital Pharmacy
2017, Vol. 52(7) 502-507
© The Author(s) 2017
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https://doi.org/10.1177/0018578717722538
DOI: 10.1177/0018578717722538
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Caitlin M. Gibson1, Sondra Davis2, and Darien Bradford2

Abstract
Purpose: Sodium nitroprusside is a vasodilator frequently used in the coronary artery bypass grafting (CABG) setting. However,
the price of a 50-mg vial of sodium nitroprusside increased from $5.00 in 2003 to up to $900 in 2016. The purpose of this review
is to help health systems balance high-quality patient care with economic responsibility. Methods: A MEDLINE literature
search was performed using the search terms "nitroprusside" and "coronary artery bypass." All English-language trials in human
subjects assessing the use of sodium nitroprusside in the setting of CABG were evaluated. The references of these studies were
also reviewed. Results: In the setting of CABG, sodium nitroprusside attenuates conduit vasospasm and reduces the incidence
of inflammation, atrial fibrillation, and acute kidney injury after surgery. However, other vasodilators are more effective at
maintaining postoperative blood pressure at goal. Conclusions: Despite its cost, sodium nitroprusside may be an appropriate
agent to use during CABG operations, but other agents should be considered for treatment of postoperative hypertension.
Keywords
coronary artery bypass, CABG, sodium nitroprusside, vasodilators, postoperative atrial fibrillation, postoperative hypertension

Introduction
US drug costs are increasing at an alarming rate. In 2014,
spending on prescription drugs increased by 12.6%, a
remarkable increase from previous drug spending growth,
which averaged about 2% per year from 2008 to 2012.1 With
the increased economic burden of many drugs, health systems must reevaluate the use of expensive medications,
ensuring the utilization is evidence-based and pharmacoeconomically sound.
One medication which has recently seen an increase in
cost is sodium nitroprusside, a potent short-acting systemic arterial and venous vasodilator. In 2003, the average
wholesale price (AWP) of a sodium nitroprusside 25 mg/1
mL vial (2 mL) was $5.00. By 2017, the AWP increased to
$360.00 to $900.00 depending upon the manufacturer.2
Sodium nitroprusside is frequently utilized for hypertensive urgency and emergency, acute congestive heart failure, and perioperative blood pressure (BP) control. Many
providers prescribe this vasodilator in the perioperative
management of coronary artery bypass grafting (CABG)
surgery.
CABG surgery is an effective revascularization procedure
for treatment of coronary artery disease. CABG is preferred
to percutaneous coronary intervention in some settings, such
as significant left main coronary artery stenosis and complex

3-vessel coronary artery disease.3 Among the Medicine,
Angioplasty, or Surgery Study (MASS-II) registry of patients
with proximal multivessel stenosis of >70% and documented
ischemia, 85.4% attained event-free survival (absence of
death, myocardial infarction, or refractory angina requiring
revascularization) at 5 years, as compared with only 56.6%
of medical therapy patients and 44.9% of patients managed
with percutaneous coronary intervention (P = .0026).4
However, risks of CABG surgery include recurrent ischemia,
stroke, bleeding, acute kidney injury (AKI), postoperative
hypertension, infection, and death. Sodium nitroprusside
may be beneficial in reducing the incidence of some complications of CABG.
Here, we review the literature on the use of perioperative
sodium nitroprusside and examine potential alternative
vasodilators.

University of North Texas System College of Pharmacy,
Fort Worth, TX, USA
2
Medical City Arlington, TX, USA
Corresponding Author:
Caitlin M. Gibson, Department of Pharmacotherapy, University of North
Texas System College of Pharmacy, 3500 Camp Bowie Blvd., RES 411D,
Fort Worth, TX 76107, USA.
Email: Caitlin.gibson@unthsc.edu

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