Chronic nitrate therapies

Despite continuing reports of adverse reactions to withdrawal from chronic occupational exposure to nitrates, there is no clear evidence of similar events in patients taking chronic nitrate therapy. However, since this risk cannot be excluded, patients taking chronic nitrates should be carefully advised and monitored. 

Nitrate therapy should be the first step in managing acute attacks of chronic stable angina if the episodes are infrequent (e.g., a few times per month). If angina occurs no more often than once every few days, then sublingual nitroglycerin tablets or spray or buccal products may be sufficient. 

Andreassi MG, Picano E, Del Ry S, Botto N, Colombo MG, Giannessi D, Lubrano V, Vassalle C, Biagini A. Chronic long-term nitrate therapy possible cytogenetic effect in humans Mutagenesis 2001 16(6) 517-21. 

Nitroglycerin and other nitrate products are useful for prophylaxis of angina when patients are undertaking activities known to provoke angina however, when angina is occurring on a regular, routine basis, chronic prophylactic therapy should be instituted. 

When coronary vasospasm occurs, the balance between oxygen supply and demand can be restored by relieving the spasm, thereby restoring normal coronary blood flow. Acute vasospasm has been successfully aborted through the use of nitroglycerin. In contrast, calcium entry blockers and long-acting nitrates have proved effective in the chronic therapy of coronary vasospasm. 

ED and vascular disease commonly coexist. They share the same risk factors and endothelial dysfunction is the common denominator. ED may develop in an otherwise asymptomatic male and be an important predictor of subsequent acute or chronic cardiac events. ED may therefore offer an opportunity for risk assessment and therapeutic intervention to reduce the chance of a subsequent cardiac presentation. Cardiac patients with ED need a careful assessment to judge the safety of sexual activity and suitability for ED treatment. Properly assessed and counselled patients can safely enjoy sexual activity. ED therapy with phosphodiesterase type five inhibitors is safe and effective providing the patient and partner are advised on their use and the importance of avoiding drug interactions, especially with nitrates. 

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