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Use of nitrates in ischemic heart disease
1Department of Medicine, University of New Mexico School of Medicine, Albuquerque.
Insights
Organic nitrates offer significant benefits for ischemic heart disease patients, improving angina and potentially reducing mortality post-myocardial infarction. Careful dosing can mitigate tolerance, enhancing their therapeutic value.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Organic nitrates possess diverse actions beneficial for ischemic heart disease.
- Their role in acute myocardial infarction suggests potential cardioprotective effects and improved mortality.
Purpose of the Study:
- To review the clinical benefits of organic nitrates in various ischemic heart disease syndromes.
- To discuss the role of nitrates in heart failure and their potential cardioprotective mechanisms.
Main Methods:
- Literature review of studies on organic nitrates in ischemic heart disease.
- Analysis of clinical trial data, including VeHfT trials, for heart failure and post-myocardial infarction patients.
Main Results:
- Nitrates are effective in stable and unstable angina, with benefits comparable to beta-blockers and calcium antagonists.
- Preliminary data suggest cardioprotective effects and improved mortality in acute infarction.
- Long-term nitrate use with hydralazine may improve heart failure outcomes, though more data are needed.
Conclusions:
- Organic nitrates are valuable agents for managing ischemic heart disease, including angina and potentially acute infarction.
- Tolerance is a manageable issue with appropriate dosing regimens.
- Emerging research on endothelial function supports the physiological role of nitrates in cardiovascular health.
Abstract:
The organic nitrates have remarkably diverse actions that are or should be beneficial in patients with ischemic heart disease. These drugs are effective in all the important ischemic syndromes. Preliminary data in patients with acute infarction suggest that the drugs may be truly cardioprotective, resulting in improved mortality. This review has not discussed the role of nitrates in congestive heart failure or LV dysfunction, a subject of great importance. The nitrates are useful adjunctive agents in these syndromes, and the two VeHfT trials support the concept that long-term nitrate administration, in conjunction with hydralazine, may favorably alter the natural history of heart failure. This cardioprotective effect is similar to that suggested for the post-MI patient. The data are not strong enough for definitive conclusions at this time. The clinical benefits of nitrates in decreasing subjective (angina) and objective indices of ischemia in stable and unstable angina, as well as limited data in asymptomatic myocardial ischemia, are unequivocal and are as favorable as those for beta blockers or calcium antagonists. Tolerance is an important problem that unfavorably influences the potential benefits of nitrate therapy. I believe that this problem can be avoided with well-designed dosing regimens. Current research into endothelial biology in health and disease has further supported a physiologic role for the organic nitrates in patients with ischemic heart disease. The nitrate-platelet story, while controversial, is promising and offers another positive rationale for nitrate administration. The concept of nitrates replenishing disordered EDRF release or action is an exciting one. Physicians should feel fortunate to have such a remarkable group of drugs available for their patients.