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Intravenous Nitroglycerin for Rest Angina: Potential Pathophysiologic Mechanisms of Action

Intravenous Nitroglycerin for Rest Angina: Potential Pathophysiologic Mechanisms of Action Abstract • Twenty patients with refractory rest angina pectoris were treated with intravenously (IV) administered nitroglycerin (mean dosage, 72.4 μg/min; range, 15 to 226 μg/min). There was a considerable reduction or abolition in the number of ischemic episodes in 85% of patients without overall substantial changes in heart rate, mean arterial BP, pulmonary capillary wedge pressure (PCWP), and pulmonary arterial mean pressure. However, those patients with an initial PCWP of more than 12 mm Hg or a systolic pressure of more than 130 mm Hg had a substantial reduction in PCWP and systolic BP following IV nitroglycerin. We conclude that IV nitroglycerin may relieve rest angina by different pathophysiologic mechanisms. In some patients, IV nitroglycerin favorably altered the hemodynamic determinants of myocardial oxygen consumption. In others, however, no change in these determinants occurred, suggesting a direct effect on the coronary circulation. (Arch Intern Med 1982;142:1806-1809) References 1. Mikolich JR, Nicoloff NB, Robinson PH, et al: Relief of refractory angina with continuous intravenous infusion of nitroglycerin. Chest 1980;77:375-379.Crossref 2. Cottrell JE, Turnderf H: Intravenous nitoglycerin. Am Heart J 1978;96:550-553.Crossref 3. Loeb HS: Intravenous nitroglycerin. Chest 1980;77:374-375.Crossref 4. Dauwe F, Affaki G, Waters DD, et al: Intravenous nitroglycerin in refractory unstable angina, abstracted. Am J Cardiol 1979;43:416. 5. Wei J, Reid PR: Quantitative determinations of trinitroglycerin in human plasma, abstracted. Am J Cardiol 1978;41:366.Crossref 6. Burggraf GW, Parker JD: Left ventricular volume changes after amyl nitrate and nitroglycerin in man, as measured by ultrasound. Circulation 1974;49:136-142.Crossref 7. Greenberg H, Dwyer EM, Jameson AG, et al: Effects of nitroglycerin on the major determinants of myocardial oxygen consumption: An angiographic and hemodynamic assessment. Am J Cardiol 1975;36:426-432.Crossref 8. Williams JF Jr, Glick G, Braunwald E: Studies on cardiac dimensions in intact unanesthetized man: V. Effects of nitroglycerin. Circulation 1965;32:767-774.Crossref 9. DeMaria AN, Vismara LA, Auditore K, et al: Effects of nitroglycerin on left ventricular cavitary size and cardiac performance in man, determined by ultrasound. Am J Med 1974;57:754-762.Crossref 10. Hoffman JIE, Buckberg GD: Transmural variation in myocardial perfusion , in Yu PN, Goodwin JF (eds): Progress in Cardiology . Philadelphia, Lea & Febiger, 1976, pp 37-79. 11. Feldman RL, Pepine CJ, Curry RC, et al: Coronary arterial responses to graded doses of nitroglycerin. Am J Cardiol 1979;43:91-96.Crossref 12. Cohn PF, Maddox D, Holman BL, et al: Effect of sublingually administered nitroglycerin on regional myocardial blood flow in patients with coronary artery disease. Am J Cardiol 1977;39:672-678.Crossref 13. Goldstein RE, Stinson EB, Scherer JL, et al: Intraoperative coronary collateral function in patients with coronary occlusive disease: Nitroglycerin responsiveness and angiographic correlations. Circulation 1974;49:298-308.Crossref 14. Mehta J, Pepine CJ: Effects of sublingual nitroglycerin on regional flow in patients with and without coronary disease. Circulation 1978;58:803-807.Crossref 15. Miller RR, Awan NA, DeMaria AN, et al: Importance of maintaining systemic blood pressure during nitroglycerin administration for reducing ischemic injury in patients with coronary disease: Effect of coronary blood flow, myocardial energetics and left ventricular function. Am J Cardiol 1977;40:504-508.Crossref 16. Brown BG, Bolson E, Peterson RB, et al: The mechanisms of nitroglycerin action: Stenosis vasodilation as a major component of the drug response. Circulation 1981;64:1089-1096.Crossref 17. Ekmekci A, Toyoshima H, Kwoczynski JK, et al: Angina pectoris: IV. Clinical and experimental difference between ischemia with S-T elevation and with S-T depression. Am J Cardiol 1961;7:412-426.Crossref 18. Gould KL, Lipscomb K, Calvert C: Compensatory changes of the distal coronary vascular bed during progressive coronary constriction. Circulation 1975;51:1085-1094.Crossref 19. MacAlpin RN: Variant angina. Am J Cardiol 1976;38:133-134.Crossref 20. Maseri A, Severi S, Deres M: 'Variant' angina: An aspect of a continuous spectrum of vasospastic myocardial ischemia. Am J Cardiol 1978;42:1019-1034.Crossref 21. Oliva PB, Breckinridge C: Arteriographic evidence of coronary arterial spasm in acute myocardial infarction. Circulation 1977;56:366-374.Crossref 22. Braunwald E: Coronary artery spasm: Mechanisms and clinical relevance. JAMA 1981;246:1957-1959.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Intravenous Nitroglycerin for Rest Angina: Potential Pathophysiologic Mechanisms of Action

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Publisher
American Medical Association
Copyright
Copyright © 1982 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1982.00340230046009
Publisher site
See Article on Publisher Site

Abstract

Abstract • Twenty patients with refractory rest angina pectoris were treated with intravenously (IV) administered nitroglycerin (mean dosage, 72.4 μg/min; range, 15 to 226 μg/min). There was a considerable reduction or abolition in the number of ischemic episodes in 85% of patients without overall substantial changes in heart rate, mean arterial BP, pulmonary capillary wedge pressure (PCWP), and pulmonary arterial mean pressure. However, those patients with an initial PCWP of more than 12 mm Hg or a systolic pressure of more than 130 mm Hg had a substantial reduction in PCWP and systolic BP following IV nitroglycerin. We conclude that IV nitroglycerin may relieve rest angina by different pathophysiologic mechanisms. In some patients, IV nitroglycerin favorably altered the hemodynamic determinants of myocardial oxygen consumption. In others, however, no change in these determinants occurred, suggesting a direct effect on the coronary circulation. (Arch Intern Med 1982;142:1806-1809) References 1. Mikolich JR, Nicoloff NB, Robinson PH, et al: Relief of refractory angina with continuous intravenous infusion of nitroglycerin. Chest 1980;77:375-379.Crossref 2. Cottrell JE, Turnderf H: Intravenous nitoglycerin. Am Heart J 1978;96:550-553.Crossref 3. Loeb HS: Intravenous nitroglycerin. Chest 1980;77:374-375.Crossref 4. Dauwe F, Affaki G, Waters DD, et al: Intravenous nitroglycerin in refractory unstable angina, abstracted. Am J Cardiol 1979;43:416. 5. Wei J, Reid PR: Quantitative determinations of trinitroglycerin in human plasma, abstracted. Am J Cardiol 1978;41:366.Crossref 6. Burggraf GW, Parker JD: Left ventricular volume changes after amyl nitrate and nitroglycerin in man, as measured by ultrasound. Circulation 1974;49:136-142.Crossref 7. Greenberg H, Dwyer EM, Jameson AG, et al: Effects of nitroglycerin on the major determinants of myocardial oxygen consumption: An angiographic and hemodynamic assessment. Am J Cardiol 1975;36:426-432.Crossref 8. Williams JF Jr, Glick G, Braunwald E: Studies on cardiac dimensions in intact unanesthetized man: V. Effects of nitroglycerin. Circulation 1965;32:767-774.Crossref 9. DeMaria AN, Vismara LA, Auditore K, et al: Effects of nitroglycerin on left ventricular cavitary size and cardiac performance in man, determined by ultrasound. Am J Med 1974;57:754-762.Crossref 10. Hoffman JIE, Buckberg GD: Transmural variation in myocardial perfusion , in Yu PN, Goodwin JF (eds): Progress in Cardiology . Philadelphia, Lea & Febiger, 1976, pp 37-79. 11. Feldman RL, Pepine CJ, Curry RC, et al: Coronary arterial responses to graded doses of nitroglycerin. Am J Cardiol 1979;43:91-96.Crossref 12. Cohn PF, Maddox D, Holman BL, et al: Effect of sublingually administered nitroglycerin on regional myocardial blood flow in patients with coronary artery disease. Am J Cardiol 1977;39:672-678.Crossref 13. Goldstein RE, Stinson EB, Scherer JL, et al: Intraoperative coronary collateral function in patients with coronary occlusive disease: Nitroglycerin responsiveness and angiographic correlations. Circulation 1974;49:298-308.Crossref 14. Mehta J, Pepine CJ: Effects of sublingual nitroglycerin on regional flow in patients with and without coronary disease. Circulation 1978;58:803-807.Crossref 15. Miller RR, Awan NA, DeMaria AN, et al: Importance of maintaining systemic blood pressure during nitroglycerin administration for reducing ischemic injury in patients with coronary disease: Effect of coronary blood flow, myocardial energetics and left ventricular function. Am J Cardiol 1977;40:504-508.Crossref 16. Brown BG, Bolson E, Peterson RB, et al: The mechanisms of nitroglycerin action: Stenosis vasodilation as a major component of the drug response. Circulation 1981;64:1089-1096.Crossref 17. Ekmekci A, Toyoshima H, Kwoczynski JK, et al: Angina pectoris: IV. Clinical and experimental difference between ischemia with S-T elevation and with S-T depression. Am J Cardiol 1961;7:412-426.Crossref 18. Gould KL, Lipscomb K, Calvert C: Compensatory changes of the distal coronary vascular bed during progressive coronary constriction. Circulation 1975;51:1085-1094.Crossref 19. MacAlpin RN: Variant angina. Am J Cardiol 1976;38:133-134.Crossref 20. Maseri A, Severi S, Deres M: 'Variant' angina: An aspect of a continuous spectrum of vasospastic myocardial ischemia. Am J Cardiol 1978;42:1019-1034.Crossref 21. Oliva PB, Breckinridge C: Arteriographic evidence of coronary arterial spasm in acute myocardial infarction. Circulation 1977;56:366-374.Crossref 22. Braunwald E: Coronary artery spasm: Mechanisms and clinical relevance. JAMA 1981;246:1957-1959.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Oct 1, 1982

References