Please summarize the literature available comparing clevidipine to nicardipine, nitroprusside and/or nitroglycerin in vascular surgery patients. Particular surgeries of interest include aortic dissection, aneurysms, carotid endarterectomies.

Comment by InpharmD Researcher

In vascular surgery patients, clevidipine has been evaluated as a safe and effective alternative to sodium nitroprusside for initial blood pressure management in acute aortic dissection, demonstrating similar efficacy with the added benefit of lower costs. Compared to nicardipine, studies show a statistically significant faster time to reach target blood pressure with clevidipine, though findings are mixed and nicardipine may carry a higher risk of hypotension. For procedures like carotid endarterectomy, clevidipine provides superior blood pressure control with significantly fewer excursions outside the target range compared to nitroglycerin. Additionally, a case report on a complex aneurysm repair highlights clevidipine's ability to maintain stable hemodynamics even during significant intraoperative blood loss.

clevidipine nicardipine nitroprusside nitroglycerin vascular surgery

Background

A 2025 prospective cohort study evaluated the efficacy and safety of clevidipine compared to standard intravenous antihypertensive therapy (labetalol with or without urapidil) for maintaining strict postoperative blood pressure control following carotid endarterectomy (CEA). The study analyzed data from 97 consecutive patients between August 2018 and October 2021, with 44 patients receiving clevidipine and 53 receiving non-clevidipine treatment based on physician preference. The primary outcome measured was the Area Under the Curve for systolic blood pressure outside the institutional target range of 130-145 mmHg (AUC-sBP), normalized per hour during the first six postoperative hours. Despite having higher baseline systolic blood pressure and a greater burden of comorbidities, patients treated with clevidipine demonstrated significantly better adherence to the target blood pressure range, with a median AUC-sBP of 120 mmHg x min/h compared to 240 mmHg x min/h in the non-clevidipine group (p <0.00001). This association remained significant after multivariable adjustment for age, sex, and preoperative systolic blood pressure (adjusted coefficient: -220 mmHg x min/h; 95% CI -293 to -146; p= 0.0001). The mean cumulative clevidipine dose was 58 ± 86 mg administered over 14 ± 10 hours. Importantly, no significant differences were observed between groups in secondary outcomes (including time to achieve initial blood pressure control, need for surgical reintervention, hematoma expansion, ICU length of stay, or in-hospital mortality) or in pre-specified adverse events such as significant hypotension, bradycardia, or new-onset atrial fibrillation. The authors conclude that clevidipine was associated with significantly tighter systolic blood pressure control within the narrow target range during the critical first six hours post-CEA compared to standard therapy with labetalol ± urapidil, without an observed increase in adverse effects, suggesting it may be a valuable option for optimizing postoperative management in this high-risk patient population. However, they acknowledge study limitations including its observational single-center design and recommend prospective randomized trials to confirm these findings. [1]

References: [1] Vives M, Regi K, Riera R, Lloret B, Castanera A, Sosa C. Efficacy and safety of Clevidipine for blood pressure control after carotid endarterectomy: a prospective cohort study, 10 November 2025, PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-7899586/v1]
Literature Review

A search of the published medical literature revealed 6 studies investigating the researchable question:

Please summarize the literature available comparing clevidipine to nicardipine, nitroprusside and/or nitroglycerin in vascular surgery patients. Particular surgeries of interest include aortic dissection, aneurysms, carotid endarterectomies.

Level of evidence

C - Multiple studies with limitations or conflicting results  Read more→


Please see Tables 1-6 for your response.

Clevidipine versus sodium nitroprusside in acute aortic dissection: A retrospective chart review
Design

Single-center retrospective chart review

N= 14
Objective To compare clevidipine versus sodium nitroprusside (SNP) as adjunct agents to esmolol for blood pressure management in aortic dissection
Study Groups

Clevidipine (n= 8)

SNP (n= 6)
Inclusion Criteria Patients older than 18 years with newly diagnosed aortic dissection initiated on esmolol plus either clevidipine or SNP in the emergency department
Exclusion Criteria Esmolol, clevidipine, or SNP infusions started at an outside hospital; use of continuous infusion of any anti-hypertensive therapy other than esmolol, clevidipine, or SNP; SBPPT not reached prior to surgical management; pregnant or breastfeeding; final diagnosis of no aortic dissection
Methods Patients were identified through inpatient orders for clevidipine or SNP with a new diagnosis of aortic dissection. The primary outcome was time to reach SBPPT goal after esmolol initiation. Efficacy was assessed using AUCSBPe. Cost data was calculated using average wholesale price.
Duration September 2010 to 2016
Outcome Measures

Primary: Time to reach SBPPT goal

Secondary: AUCSBPe, cost analysis
Baseline Characteristics   Clevidipine (n= 8) SNP (n= 6)
Age, years 66 ± 17.5 49.6 ± 14
Gender, male (%) 6 (75) 5 (83.3)
Results   Clevidipine (n= 8) SNP (n= 6) p-value
Median time to reach SPBPT goal, hrs 1.68 1.03 0.99
AUC outside of SBPPT goal, mm Hg ∗min ∗hr−1 206.9 538.9 0.11
Cumulative cost of total mg/day $885.84 $4158 <0.001
Adverse Events No specific adverse events reported
Study Author Conclusions

Clevidipine administration during initial medical management of aortic dissection showed similar efficacy compared to SNP when used as adjunct therapy to esmolol. Clevidipine is a less costly, reasonable alternative to SNP in acute aortic dissection.
Critique

The study's retrospective design and small sample size limit the generalizability of the findings. Cost data based on AWP may not reflect actual institutional costs. Further studies with larger sample sizes are needed to validate these results.

 

References:
[1] [1] Ulici A, Jancik J, Lam TS, Reidt S, Calcaterra D, Cole JB. Clevidipine versus sodium nitroprusside in acute aortic dissection: A retrospective chart review. Am J Emerg Med. 2017;35(10):1514-1518. doi:10.1016/j.ajem.2017.06.030
Clevidipine as a therapeutic and cost-effective alternative to sodium nitroprusside in patients with acute aortic syndromes
Design

Retrospective chart review

N= 135
Objective To assess the efficacy and safety of intravenous clevidipine compared to sodium nitroprusside in patients with acute aortic syndrome (AAS)
Study Groups

Clevidipine (n= 85)

Sodium nitroprusside (n= 50)
Inclusion Criteria Patients admitted to the Cleveland Clinic coronary intensive care unit from 2013–2016 with a diagnosis of acute aortic syndrome
Exclusion Criteria Patients without a confirmed diagnosis of AAS, incomplete hemodynamic data, or those who received both clevidipine and SNP within the first 24-hour period
Methods

Retrospective review of electronic medical records, comparing intravenous clevidipine and sodium nitroprusside within the coronary intensive care unit. Patients with AAS had continuous intra-arterial monitoring via radial artery and hemodynamic data was frequently documented.
Duration 2013 to 2016
Outcome Measures

Primary: Blood pressure at one, three, and six hours

Secondary: Time to achieve blood pressure target, in-hospital mortality, rates of hypotension and bradycardia
Baseline Characteristics   Clevidipine (n=85) SNP (n=50)
Gender, male 48 (56.0%) 27 (54.0%)
Age, years, mean ± SD 65.4±15.4 61.3±16.4
Coronary artery disease 15 (30.0%) 27 (31.8%)
Hypertension 73 (85.9%) 46 (92.0%)
Atrial fibrillation 20 (23.5%) 8 (16.0%)
Hyperlipidemia 36 (42.4%) 18 (36.0%)
Smoking 27 (31.8%) 18 (36.0%)
Diabetes mellitus 11 (12.9%) 5 (10.0%)
CKD 11 (12.9%) 4 (8.0%)
SBP at presentation, mean±SD 146.3±25.8 155.5±29.9
DBP at presentation, mean±SD 74.6±16.3 74.62±18.9
HR at presentation, mean±SD 74.01±13.8 73.14±12.4
Results   Clevidipine (n=85) SNP (n=50) p-value
SBP at 1 h, mean±SD 123.6±18 126.8±27.6 0.500
DBP at 1 h, mean±SD 60.1±11.7 61.6±12.7 0.500
SBP at 3 h, mean±SD 119.1±16 125.0±20.3 0.050
DBP at 3 h, mean±SD 57.6±22.4 59.4±10.3 0.340
SBP at 6 h, mean±SD 115.05±16.0 121.3±19.3 0.060
DBP at 6 h, mean±SD 64.3±9.0 60.8±13.6 0.600
HR at 6 h, mean±SD 68.8±9.4 75.6±12.5 0.001
Time to achieve target BP (h) 2.18±2.7 2.21±2.19 0.900
Hypotension 40 (47.6%) 16 (32.0%) 0.103
Bradycardia 22 (26.5%) 4 (8.0%) 0.012
In-hospital mortality 9 (10.6%) 7 (14.0%) 0.588
Adverse Events Higher incidence of bradycardia in the clevidipine group (26% vs 8%; p=0.012). No significant difference in hypotension rates
Study Author Conclusions

Intravenous clevidipine is a safe and effective alternative to sodium nitroprusside for managing high blood pressure during acute aortic dissection, offering similar outcomes and potentially lower costs.
Critique

The study's retrospective design may introduce bias, and the small sample size limits the analysis of hard endpoints like mortality. However, it provides valuable insights into the cost-effectiveness and safety of clevidipine as an alternative to sodium nitroprusside in acute aortic syndrome management. Further prospective studies are needed to confirm these findings.

 

References:
[1] [1] Alviar CL, Gutierrez A, Cho L, et al. Clevidipine as a therapeutic and cost-effective alternative to sodium nitroprusside in patients with acute aortic syndromes. Eur Heart J Acute Cardiovasc Care. 2020;9(3_suppl):S5-S12. doi:10.1177/2048872618777919
Impact of Clevidipine Versus Nicardipine on Time in Range when Lowering Blood Pressure
Design Multi-center, retrospective chart review N= 200 (100 matched pairs)
Objective To evaluate efficacy and safety outcomes associated with current use of clevidipine and nicardipine across a variety of indications in a hospital system
Study Groups Nicardipine (n= 100) Clevidipine (n= 100)
Inclusion Criteria Age ≥18 and <90 years old treated with nicardipine or clevidipine IV infusion at an acute care facility within the health system from June 1, 2020 to June 30, 2021
Exclusion Criteria Pregnant or experiencing eclampsia post-partum; no documented blood pressure goal; initiated on a nicardipine and/or clevidipine drip prior to transfer from one acute care facility to another within 24 hours of infusion initiation; transferred from an internal acute care facility to an external acute care facility prior to discharge; in-hospital mortality or discharged within 24 hours of infusion initiation; or no match in the other group for both indication for blood pressure control and SBP
Methods Patients were matched in a one-to-one fashion based on indication for blood pressure control and similar pre-intervention systolic blood pressures. Clevidipine starting dose 2 mg/hr, max dose 16 mg/hr, titrate by 2 mg every 2 minutes or every 5 minutes when within 20 mmHg of the SBP goal; nicardipine starting dose 2.5 mg/hr, max dose 15 mg/hr, titrate by 2.5 mg every 15 minutes.
Duration June 1, 2020 to June 30, 2021
Outcome Measures

Primary: Time within target blood pressure range

Secondary: Time to blood pressure goal, incidence of hypotension during infusion, use of rescue medications during infusion
Baseline Characteristics   Nicardipine (n= 100) Clevidipine (n= 100)
Age, years (mean ± SD) 62.1 ± 15.5 63.9 ± 16.6
Male 56% 58%
Body mass index, kg/m2 (mean ± SD) 30.0 ± 8.2 27.2 ± 6.6
Hypertension 59% 54%
Diabetes mellitus 29% 19%
Chronic kidney disease 21% 16%
Smoking 53.2% 51.4%
Alcohol use 54.1% 56.7%
Intubated during infusion 43% 24%
Results   Nicardipine (n= 100) Clevidipine (n= 100) p-value
Percent of time in target BP range (mean ± SD) 59.0 ± 27.9 55.2 ± 29.2 0.356
Time to target BP goal, min (median, IQR) 34.0 (14.5-57.0) 20.0 (7.0-43.0) 0.013
Incidence of hypotension 17% 10% 0.093
Rescue medications required 29% 33% 0.541
Adverse Events Numerically higher rates of hypotension with nicardipine than clevidipine, but not significant (17% vs 10%; P = 0.093)
Study Author Conclusions This study shows a statistically significant difference in time to target blood pressure range with clevidipine compared to nicardipine. Although there was no difference in the percentage of time in blood pressure range, nicardipine was associated with a non-significant increase in the incidence of hypotension.
Critique The study's strength lies in its larger sample size compared to previous studies and its evaluation of a broad range of patients. However, it was underpowered for the primary endpoint and had limitations in charting frequency for blood pressure accuracy. The institutional titration protocols deviated from package inserts, potentially affecting results. Additionally, there was underrepresentation of certain patient groups due to matching constraints, and poor documentation made it difficult to ascertain reasons for switching agents.

 

References:
[1] [1] Armstrong KJ, Shepard K, Horsfield M, Levine AR, O'Sullivan DM, Zeiner AL. Impact of Clevidipine Versus Nicardipine on Time in Range when Lowering Blood Pressure. J Pharm Pract. 2025;38(2):256-263. doi:10.1177/08971900241279638
A retrospective cohort study comparing clevidipine and nicardipine for the management of blood pressure in acute aortic dissection in the emergency department
Design

Single-center, retrospective, observational cohort study

N= 17
Objective To compare the time to SBP goal utilizing clevidipine vs nicardipine in patients with suspected acute aortic dissection
Study Groups

Clevidipine (n= 10)

Nicardipine (n= 7)
Inclusion Criteria Patients for which an "Aorta Alert" was called who received either clevidipine or nicardipine in the ED from 1/1/2019 to 9/30/2019
Exclusion Criteria Patients who received both nicardipine and clevidipine at any time during the study period
Methods

Patients received either clevidipine or nicardipine in the ED. Data on patient demographics, clevidipine doses, nicardipine doses, systolic blood pressures, and systolic blood pressure goal values were collected using clinical progress notes and EPIC medication order information. The primary outcome was the time to reach goal SBP in the ED.
Duration 1/1/2019 to 9/30/2019
Outcome Measures

Primary: Time to reach goal SBP

Secondary: Incidence of hypotension, mortality during encounter, median drug amount administered during ED encounter
Baseline Characteristics   Clevidipine (n=10) Nicardipine (n=7) p-Value
Age (± SD) 73 ± 16 59 ± 13 0.319
Gender, male (%) 8 (80) 6 (86) 0.761
Aortic Dissection type A (%) 7 (70) 3 (42) 0.585
Documented history of hypertension (%) 6 (60) 4 (57) 0.906
Documented RPH response to bedside (%) 6 (60) 4 (57) 0.906
Median length of time spent in the Emergency Department, min 140 75 0.383
IV antihypertensive prior to arrival (%) - Nicardipine 3 (30) 5 (71) 0.092
IV antihypertensive prior to arrival (%) - Labetalol 1 (10) 0 (0) 0.009
SBP upon drug initiation in ED (± SD) 162 ± 38 141 ± 40 0.39
Lowest SBP in ED (± SD) 114 ± 6.5 104 ± 12 0.35
Results   Clevidipine (n=10) Nicardipine (n=7) p-value
Median time to reach goal SBP, min 23 9 0.109
Hypotension 0 (0) 3 (43) 0.023
Mortality during encounter (%) 1 (10) 0 (0) 0.388
Median amount of drug administered during ED encounter, mg 4.5 7.4 *
Adverse Events See above for hypotension
Study Author Conclusions

No difference in time to goal blood pressure between nicardipine and clevidipine was identified. However, the small sample size of this study may have limited its ability to detect a difference if one exists. Clinical differences between the products still warrant additional investigation.
Critique

The study was limited by its small sample size, which may have obscured any statistically significant differences in primary outcomes. Additionally, manual documentation of blood pressures and lack of interoperability between IV pump and EHR could introduce bias and error. Variations in pre-hospital care may have influenced outcomes, and the study's definition of hypotension may not be clinically significant. A larger trial is needed to confirm these results.

 

References:
[1] [1] Albright, M, Truccolo DS. A retrospective cohort study comparing clevidipine and nicardipine for the management of blood pressure in acute aortic dissection in the emergency department. Accessed February 20, 2026.

 

Intraoperative clevidipine use to manage an acute hypertensive episode in a patient with a simultaneous kidney-pancreatic transplant

Design

 Case report

Case presentation

A 49-year-old male presents with a history of fever, leukopenia, poorly controlled hypertension, and renal dysfunction who developed a pseudoaneurysm (PSA) three months after a simultaneous kidney-pancreas transplant (SKPT). He underwent emergency laparotomy for PSA excision and graft transplantectomy. Due to refractory hypertension before the surgical incision, a continuous infusion of clevidipine was initiated and titrated to effectively control blood pressure. During the procedure, the patient experienced significant blood loss (1200 mL) from an accidental venous rupture, but clevidipine maintained stable hemodynamics without fluctuations. Postoperatively, the clevidipine infusion was continued in the ICU and gradually weaned over ten hours. The patient was successfully extubated, and long-term blood pressure control was achieved with oral medications.

Study Author Conclusions

 In relation with its pharmacological properties, we consider that clevidipine is an effective and safe drug in this case.

 

References:
[1] [1] Pascual MJ, Sastre JA, Calvo JM. Intraoperative clevidipine use to manage an acute hypertensive episode in a patient with a simultaneous kidney-pancreatic transplant. J Clin Anesth. 2018;45:53-54. doi:10.1016/j.jclinane.2017.11.017
Clevidipine versus nitroglycerin for blood pressure control during carotid endarterectomy: a cohort study
Design

Single-center retrospective observational study

N= 40
Objective To evaluate the role of clevidipine to control blood pressure during carotid endarterectomy
Study Groups

Clevidipine (n= 20)

Nitroglycerin (n= 20)
Inclusion Criteria Patients undergoing elective carotid endarterectomy from October 2024 to March 2025 who received clevidipine or nitroglycerin for intraoperative blood pressure management
Exclusion Criteria Patients who underwent other vascular surgical procedures involving the carotid artery, showed an ejection fraction lower than 50% or declined to participate
Methods

Patients received clevidipine or nitroglycerin for intraoperative blood pressure management. Clevidipine was initiated at 2 mg/h and titrated up to 10 mg/h. Nitroglycerin was initiated at 5 mcg/min and titrated up to 100 mcg/min. The primary endpoint was the area under the curve of systolic blood pressure excursions outside the target range of 140–160 mmHg.
Duration October 2024 to March 2025
Outcome Measures

Primary: Area under the curve of systolic blood pressure excursions outside the target range
Baseline Characteristics   Clevidipine group (n= 20) Nitroglycerin group (n= 20) p-value
Male sex 12 (60%) 14 (70%) 0.51
Age, years 76 (74–82) 78 (72–80) 0.54
Active Smoker 2 (10%) 9 (45%) 0.03
Diabetes 7 (35%) 7 (35%) 1.00
Hypertension 19 (95%) 17 (85%) 0.61
Dyslipidemia 18 (90%) 19 (95%) 1.00
Results   Clevidipine group (n= 20) Nitroglycerin group (n= 20) p-value
Time outside SBP target range, min (IQR) 10.0 (5.0 to 16.3) 37.5 (30.0 to 51.3) <0.001
AUC for SBP excursions, mmHg × min (IQR) 29.59 (15.83 to 49.35) 60.30 (42.79 to 74.38) 0.005
Adverse Events No significant differences in clinical complications between groups. No major adverse events such as stroke or in-hospital death were observed
Study Author Conclusions Clevidipine was associated with significantly fewer blood pressure excursions outside the target goal range compared to nitroglycerin during carotid endarterectomy.
Critique

The study's strengths include standardized monitoring protocols and rigorous quantitative methods. However, the retrospective design and small sample size limit the ability to establish causal relationships and assess less frequent adverse events. The single-center nature restricts generalizability to other institutions with different practices.

 

References:
[1] [1] Labanca R, Ursoleo JD, Fresilli S, et al. Clevidipine versus nitroglycerin for blood pressure control during carotid endarterectomy: a cohort study. BMC Anesthesiol. 2025;26(1):45. Published 2025 Dec 15. doi:10.1186/s12871-025-03543-8