Nitroglycerin heart failure

Nitroglycerin remains the dmg of choice for treatment of angina pectoris. It has also been found useful for the treatment of congestive heart failure, myocardial infarction, peripheral vascular disease, such as Raynaud s disease, and mitral insufficiency, although the benefits of nitroglycerin in mitral insufficiency have been questioned. 

FIGURE 8-2. General treatment algorithm for acute decompensated heart failure (ADHF) based on clinical presentation. IV vasodilators that may be used include nitroglycerin, nesiritide, or nitroprusside. Metolazone or spironolactone may be added if the patient fails to respond to loop diuretics and a second diuretic is required. IV inotropes that may be used include dobutamine or milrinone. (D/C, discontinue HF, heart failure SBP, systolic blood pressure.) (Reprinted and adapted from J Cardiac Fail, Vol 12, pages el-el 22, copyright 2006, with permission from Elsevier.)... 

The primary direct result of an effective dose of nitroglycerin is marked relaxation of veins with increased venous capacitance and decreased ventricular preload. Pulmonary vascular pressures and heart size are significantly reduced. In the absence of heart failure,... 

Lahiri, A., et al. 1986. Buccal nitroglycerin tablets in heart failure. Ann Intern Med 105 141. 

Nitroglycerine Isosorbide dinitrate Treatment of angina pectoris and second-line therapy in congestive heart failure... 

Bauer JA, Fung HL, Concurrent hydralazine administration prevents nitroglycerin-induced hemodynamic tolerance in experimental heart failure, Circulation 1991 84 35-39,... 

Examples of specific drugs used in the treatment of chronic heart failure include digitalis glycosides (e.g., digoxin, positive inotropic agent), diuretics (hydrochlortiazide and furosemide), and vasodilators (nitrates such as nitroglycerin, ACE inhibitors, such as captopril, and hydralazine). 

Bauer, J., Balthasar, J., and Fung, H., Application of pharmacodynamic modeling for designing time-variant dosing regimens to overcome nitroglycerin tolerance in experimental heart failure, Pharmaceutical Research, Vol. 14, No. 9, 1997, pp. 1140-1145. 

Sanghera, S.S. Goldberg, A.A.J. Parson, D.F. Buccal nitroglycerin in elderly patients with congestive heart failure. Practitioner 1985, 229, 1054-1055. 

Loh E, Elkayam U, Cody R, Bristow M, Jaski B, Coined WS. A randomized multicenter study comparing the efficacy and safety of intravenous milrinone and intravenous nitroglycerin in patients with advanced heart failure. J Card Fail 2001 7(2) 114-21. 

FIGURE 14-8. General treatment algorithm for advanced/decompensated heart failure based on clinical presentation. Intravenous vasodilators that may be used include nitroglycerin, nesiritide, and nitroprusside. (Adapted with permission from Am Heart J 1998 135 5293-309.)... 

The VMAC Investigators. Intravenous nesiritide vs nitroglycerin for treatment of decompensated congestive heart failure A randomized, controlled trial. JAMA 2002 287 1531-1540. 

STE and NSTE ACS, class I indication in patients whose symptoms are not fully relieved with three sublingual nitroglycerin tablets and initiation of, 6-blocker therapy, in patients with large infarctions, those presenting with heart failure or those who are hypertensive on presentation... 

One SL nitroglycerin (NTG) tablet should be administered every 5 minutes for up to three doses to relieve myocardial ischemia. If patients have previously been prescribed sublingual NTG and ischemic chest discomfort persists for more than 5 minutes after the first dose, the patient should be instructed to contact emergency medical services before self-administering subsequent doses in order to activate emergency care sooner. IV NTG then should be initiated in all patients with an ACS who do not have a contraindication and who have persistent ischemic symptoms, heart failure, or uncontrolled blood pressure, and should be continued for approximately 24 hours after ischemia is relieved (see Table 16-4). Importantly, other life-saving therapy, such as ACE inhibitors or /3-blockers, should not be witheld because the mortality benefit of nitrates is unproven. Nitrates promote the release of nitric oxide from the endothelium, which results in venous... 

Nitrate compounds (e.g., nitroglycerin, isosorbide mononitrate) may be used in the reducing esophageal spasm, managing heart failure, and decreasing postoperative hypertension. 

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