Intravenous nitroglycerin in the treatment of spontaneous angina pectoris: a prospective, randomized trial.

Abstract

SUMMARY A prospective, randomized study of i.v. nitroglycerin (TNG) 276 included a randomized control, which is especially important in assessing the therapeutic efficacy of antianginal agents because of the spontaneous variability in the occurrence of ischemic episodes.'6We therefore performed a prospective, randomized trial comparing the therapeutic effect of i.v. TNG with that of oral isosorbide dinitrate (ISDN) in combination with 2% nitroglycerin ointment (NO) in patients with repetitive episodes of spontaneous angina. Although we might have chosen other regimens, we studied these two long-acting agents because they are commonly used together to manage refractory unstable angina. Methods Patient PopulationForty consecutive patients of both sexes admitted to the coronary care units of the Dartmouth-Hitchcock Medical Center with a diagnosis of unstable angina pectoris who satisfied the following entry criteria were prospectively enrolled in this investigation. All patients had sustained at least two episodes of spontaneous myocardial ischemia during a 48-hour pretreatment control period. In 38 of 40 patients, ischemic episodes were accompanied by typical cardiac pain or discomfort; in two patients, some ischemic episodes were reflected only by spontaneous electrocardiographic changes not accompanied by symptoms. To confirm that symptoms were related to myocardial ischemia, we required that chest pain last less than 15 by guest on May 9, 2018 http://circ.ahajournals.org/ Downloaded from

Exogenous nitric oxide reduces glucose transporters translocation and lactate production in ischemic myocardium in vivo

“…First, the blood concentration of NTG achieved in the ischemic territory, equal to Ϸ1 g͞ml, was higher than that found in patients treated with sublingual, transdermal, and i.v. NTG administration (33,34). It remains to be determined whether similar effects occur at lower doses.…”

Coronary bypass surgery for unstable angina.

“…Subsequent advances in medical management (aggressive use of f-blockers, calcium entryblocking agents, and intravenous nitroglycerin) have had a beneficial effect on symptoms during the acute phase. [15][16][17] However, the recent randomized study from Johns Hopkins'5 demonstrated a very high rate of "failure of medical therapy"; at 4 months in the nifedipine-treated group the failure rate was 44% and in those not treated with nifedipine it was 62%.…”

“…These therapies control pain but not all episodes of myocardial ischemia. 17 Moreover, many episodes of myocardial ischemia are painless, and it seems reasonable that ischemia with or without pain is the precursor of myocardial infarction and death; thus, it is easy to understand why modern pharmacologic therapy has not had a great impact in this disorder. '5-17 However, aspirin administered for 4 months had a beneficial effect on the incidence of myocardial infarction at 4 months and 1 year and the incidence of cardiac death at 1 year but not at 4 Coronary bypass surgery.…”

Medical compared with surgical management of unstable angina. 5-year mortality and morbidity in the Veterans Administration Study.

“…Thus, more than three fourths of the patients failing medical treatment occurred within 18 months of randomization. In the first 30 days, the crossover rate was higher among patients with type 2 than among those with type 1 (19 Figure 2). When mortality was analyzed according to prerandomization stratification by clinical presentation, there were also no significant differences shown in survival ( Figures 3A, 3B).…”