Pulsus alternans induced by glyceryl trinitrate paste in a patient with alcoholic cardiomyopathy

Application of a small dose of glyceryl trinitrate paste (0.25 in) resulted in severe left ventricular dysfunction with the appearance of pulsus alternans in a patient with alcoholic cardiomyopathy. The echocardiogram showed a reduction in the amplitude and velocity of motion of the left ventricular posterior wall on alternate beats. Leg elevation promptly reversed the pulsus alternans, and the echocardiographic abnormality. Glyceryl trinitrate paste should be used with caution and under close supervision in patients with liver dysfunction.