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Nitroglycerin: The "Mini" Wonder Drug
Thomas B. Graboys and Bernard Lown Circulation 2003;108;e78-e79 DOI: 10.1161/01.CIR.0000086629.67552.3A Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 Copyright 2003 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online ISSN: The online version of this article, along with updated information and services, is located on the World Wide Web at: Subscriptions: Information about subscribing to Circulation is online at Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of WoltersKluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax: 410-528-8550. E-mail: Reprints: Information about reprints can be found online at CARDIOLOGY PATIENT PAGE CARDIOLOGY PATIENT PAGE Nitroglycerin
The "Mini" Wonder Drug

Thomas B. Graboys, MD; Bernard Lown, MD Newer drugs quickly replace tery and an increased bodily demand forward,inhalingdeeply,andbearing older remedies. This has not for the heart to pump more blood.
down as if for a bowel movement.
been the case with nitroglyc- Nitroglycerin achieves its salutary ac- Nitroglycerin announces its action erin, now in continuous medical use tion both by dilating coronary vessels by a gentle tingling sensation under the for more than a century. Although and by decreasing the heart's work- tongue. Its vascular dilating action is other applications for it have been load. The latter is accomplished by not limited to the coronary arteries found in cardiology, nitroglycerin is reducing peripheral return of blood to supplying blood to the heart. This is the mainstay for affording rapid, in- the heart, as well as by lessening the demonstrated by frequent facial flush, deed almost immediate, relief for an- resistance to the outflow of blood from lightheadedness, or throbbing fullness gina pectoris. Patients who have mas- the heart into the main arterial circula- or sensation of warmth in the head.
tered the proper use of this agent tion. The exact mechanism accounting Some patients complain of headache regard it as a "wonder drug." At a time for these effects remains unclear, of varying severity. When the patient when the cost of pharmaceuticals is though cumulating evidence points to is assured that the mild untoward reac- growing out of reach for many, nitro- the release of the powerful vasodilator tions are but part of the drug's physi- glycerin is still obtainable for pennies substance nitric oxide from endothelial ological repertoire, symptoms are gen- and remains one of the best buys in cells that line vessel walls, from erally minimized or totally obviated.
smooth muscle embedded in vessels A good practice is to transfer a and perhaps even from platelets.
number of nitroglycerin tablets to a What Is Angina and Why
small pillbox and to make them readily How to Use Nitroglycerin
available. Generally, nitroglycerin Relieving angina pectoris is the invari- Nitroglycerin, if taken properly, can maintains its potency when secured in able indication for nitroglycerin. This help patients with angina achieve a a tightly closed bottle for 3 to 4 unique discomfort located behind the pain-free and unrestricted lifestyle.
breastbone is provoked by a temporary Simple instructions at the very first insufficiency of blood flow to heart encounter with a physician help en- When Should Nitroglycerin
muscle. Angina does not indicate a courage the free use of this drug. When Be Taken?
"heart attack," nor is there ensuing a tablet is needed, it is placed under the Nitroglycerin is more promptly effec- heart muscle damage. The fact is that tongue and allowed to dissolve. Gen- tive when taken at the very inception anginal discomfort is not caused by erally, this takes about 20 to 30 sec- of chest discomfort. It is even better to abrupt closure of a coronary artery, but onds. Nitroglycerin can be chewed, but take a pill in anticipation of angina.
rather results from a temporary mis- is less effective when swallowed with- Most patients having angina are aware match between restricted blood flow in out being dissolved. Positive drug ac- of the factors that produce discomfort.
a preexisting obstructed coronary ar- tion is hastened by sitting, leaning The circumstances are generally exer- From the Lown Cardiovascular Center, Brigham and Women's Hospital, Boston, Mass.
Correspondence to Thomas B. Graboys, MD, Lown Cardiovascular Center, 21 Longwood Ave, Brookline, MA 02446. E-mail tgraboys@partners.org or ckenney@partners.org (Circulation. 2003;108:e78-e79.)
2003 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
September 16, 2003
tion, excitement, or deep emotion. An- episode of angina that does not imme- riencing angina that is not substantially gina is most likely under the following diately abate when they stop whatever relieved by nitroglycerin, or if the conditions: When walking briskly out- they are doing.
discomfort recurs after a single nitro- doors on a cold, windy, or humid day; Patients commonly harbor the su- glycerin pill, seeking the closest med- when hurrying with a heavy briefcase perstitious notion that the less they ical facility is an appropriate response.
or bundles; when exerting after a resort to nitroglycerin, the less serious heavy meal; when working under the their affliction. Some fear addiction, pressure of a deadline; when speaking habituation, or loss of nitrate efficacy Fear and anxiety prevail among coro- in public; when engaging in sexual at a time when they might really need nary heart disease patients. This is not activity; and when worried, tense, and it. Some are impeded in its use because at all surprising, as many are aware especially when angry. Nitroglycerin of unease in exposing the fact that they that sudden cardiac death or a dis- taken to prevent attacks (prophylac- suffer from a heart condition for fear abling heart attack are possible out- tically) under such circumstances is of losing a job or arousing undue comes of their condition. The occur- anxiety in a spouse. A common ratio- rence of angina pectoris is therefore a After taking a nitroglycerin under nalization is that because the discom- disquieting reminder of one's uncer- the tongue (sublingually), relief is fort is transient, far preferable to taking tain hold on life. A wealth of published likely to follow within one to two a pill is to stop the exertion that pro- data documents psychological stress as minutes. Not all types of chest pain voked the angina in the first place. It is an adverse prognostic factor for pa- will respond to nitroglycerin. This tients with coronary artery disease.
therefore important for the patient to Stress is invariably diminished by pur- proves helpful in differentiating symp- understand that nitroglycerin is not poseful activity. Being able to termi- toms caused by impaired blood flow in habit-forming and is neither a narcotic nate an anginal episode promptly, or the coronary vessels or a diversity of nor a painkiller. It is permissible to better still to prevent its occurrence, noncardiac conditions. Nitroglycerin take nitroglycerin numerous times dur- puts one in control. Taking nitroglyc- may interact with other cardiac medi- ing the course of the day without erin is a self-empowering act. Being in cation, and this should be discussed control ameliorates fear and anxiety.
with a physician.
We encourage patients with newly When nitroglycerin is properly and diagnosed angina to take a sublingual frequently used, it will improve the Why Many Patients do Not
nitroglycerin in our presence when patient's quality of life. Patients expe- they are not experiencing angina.
riencing angina can avoid costly inter- A common practice is to hand the While the drug is acting, explanation ventions by being treated medically.
patient a prescription, with the sole of its pharmacology and beneficent Neither life's duration nor the patient's instruction to put the pill under the action proves valuable. These patients well-being is thereby compromised.
tongue during chest discomfort. The almost never have side effects and Taking nitroglycerin freely, without doctor often alerts the patient that the more readily resort to its use.
anxiety, fosters self reliance—a highly use of nitroglycerin may be associated A few admonitions are in order.
desirable goal for all patients.
with lightheadedness or a throbbing Viagra, used to treat erectile dysfunc- headache. Patients so instructed infre- tion, is not indicated for patients taking quently resort to nitroglycerin. They oral nitrates, nitroglycerin patches, or This work was supported in part by the Lown generally reserve it for a more severe sublingual preparations. If one is expe- Cardiovascular Research Foundation.

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