Unexpected, tolerance-devoid vasomotor and platelet actions of pentaerythrityl tetranitrate

Efficacy of nitrate therapy is limited by tolerance. A surprising upregulation of ex vivo platelet activity, a decrease in platelet thiol levels, and an enhanced release of vasoconstrictors from platelets is associated with enhanced superoxide-mediated oxidant stress leading to vascular tolerance to nitrates. We tested the NO-donor pentaerythrityl tetranitrate (PETN), which to date had not been precisely tested either with regard to the induction of tolerance or to a potential development of changes in platelet activity in comparison with glycerol trinitrate (GTN). Long-term instrumented dogs nonintermittently received: 1.5 microg/kg/min GTN, i.v., with or without vitamin C (55 microg/kg/min, i.v.) or PETN 4 x 60 mg/day orally for 5 days. Tested daily were (a) the dilation of the epicardial arteries, (b) thrombin-induced (0.5 U/ml) increases of the intracellular Ca2+ concentration and aggregability of platelets, (c) concentrations of reduced low-molecular-weight thiols (LMTs) in plasma and platelets, and (d) formation of reactive oxygen species (ROSs). During nonintermittent PETN and during GTN with additional vitamin C, a 9.8 +/- 0.4% coronary artery dilation was observed in contrast to that with GTN alone, which resulted in complete tolerance at day 4. This vascular tolerance was associated with enhanced platelet activity and formation of ROSs (incubated platelets) and a 38 +/- 3% reduction in LMT. These unfavorable changes were absent in the presence of PETN or with additional vitamin C as an antioxidant. Vascular tolerance associated with platelet upregulation is avoided either by nonintermittent nitroglycerin (5 days) when vitamin C is coadministered or by pentaerythrityl tetranitrate without the coadministration of vitamin C.