Use of nitrates in the treatment of unstable and variant angina

Unstable angina is a clinical syndrome that includes patients with new onset of angina, a change in a previous stable pattern, or the development of chest pain at rest. Generally, more than 90% of patients with this syndrome have significant fixed atherosclerotic coronary artery disease. Other complex, interacting pathophysiological mechanisms may include coronary vasoconstriction, plaque rupture and thrombosis. Therapeutic strategies aim at either reduction of myocardial oxygen demand or restoration of coronary blood flow. Both alternatives have been suggested as treatment of choice. However, as long as the pathophysiological mechanism(s) is unknown in the individual case, the treatment will mainly be empirical or based on results from clinical trials of heterogeneous groups of patients with unstable angina with probably varying aetiology. The results from such studies indicate that some strategies may be of value, but others may even be harmful in treatment of patients with this unstable syndrome. In this situation nitrates seem to be a safe drug which may be used in most forms of irrespective of the underlying pathophysiological mechanism(s).