JAMA ; — Impact of IV nitroglycerin in the management of acute decompensated heart failure. Curr Heart Fail Rep ; 12 — J Card Fail ; 4 —9. Do IV nitrates improve dyspnea in acute heart failure syndromes more than alternative pharmacologic interventions? Ann Emerg Med ; 66 —9. Impact of a high-dose nitrate strategy on cardiac stress in acute heart failure: a pilot study. J Intern Med ; — Treatment of severe decompensated heart failure with high-dose IV nitroglycerin: a feasibility and outcome analysis.
Ann Emerg Med ; 50 High-dose iv isosorbidedinitrate is safer andbetter than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. J Am Coll Cardiol ; 36 —7. Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus high-dose furosemide plus low-dose isosorbide dinitrate in severe pulmonary edema. Lancet ; — The safety of IV diuretics alone versus diuretics plus parenteral vasoactive therapies in hospitalized patients with acutely decompensated heart failure: a propensity score and instrumental variable analysis using the Acutely Decompensated Heart Failure National Registry ADHERE database.
Early vasoactive drugs improve heart failure outcomes. Congest Heart Fail ; 15 — Effect of adding nitroglycerin to early diuretic therapy on the morbidity and mortality of patients with chronic kidney disease presenting with acute decompensated heart failure.
Hosp Pract ; 39 — Haemodynamic advantages of isosorbide dinitrate over furosemide in acute heart failure following myocardial infarction. Lancet ; 1 —3. Modulation of novel cardiorenal and inflammatory biomarkers by IV nitroglycerin and nesiritide in acute decompensated heart failure.
Circ Heart Fail ; 4 —5. Circulation ; 62 :e—e Circulation ; — Eur J Heart Fail ; 14 — Eur J Heart Fail ; 17 — The Canadian Cardiovascular Society heart failure management guidelines update: focus on acute and chronic heart failure. Can J Cardiol ; 29 — Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines?
Eur J Heart Fail ; 15 — IV therapies in acute heart failure—lack of effect or lack of well powered studies? Eur J Heart Fail ; 16 —7. Nitrates for acute heart failure syndromes. Tolerance to IV NTG in patients with congestive heart failure: role of increased intravascular volume, neurohumoral activation and lack of prevention with N-acetylcysteine.
J Am Coll Cardiol ; 16 — Evidence supporting abnormalities in nitric oxide synthase function induced by nitroglycerin in humans. J Am Coll Cardiol ; 38 — Nitrate therapy: new aspects concerning molecular action and tolerance. Prevention of tolerance to hemodynamic effects of nitrates with concomitant use of hydralazine. J Am Coll Cardiol ; 26 — Isosorbide dinitrate and hydralazine in a fixed-dose combination produces further regression of left ventricular remodeling in a welltreated black population with heart failure: results from A-HeFT.
J Card Fail ; 13 —9. Prevention of tolerance to hemodynamic effects of nitrates with concomitant use of hydralazine in patients with chronic heart failure. Prevention and reversal of nitrate tolerance in patients with congestive heart failure.
This strategy is more applicable in managing chronic heart failure. It is well documented that patients receiving IV organic nitrate develop haemodynamic tolerance in as little as 4 hours.
Nitrite NaNO2 does not suffer this limitation and thus may have a future therapeutic role. Physiologically, in healthy subjects, NaNO2 selectively dilates pulmonary capacitance vessels and results in a modest reduction in systemic arterial pressure. Ormerod et al. They concluded that NaNO2 has an attractive profile during short-term IV infusion, may have favorable effect in decompensated HF and warrants further evaluation with longer infusion regimens.
A case for the early use of high-dose nitrates in AHF can be made based on the current literature. This is supported by the knowledge of their mechanism of action given the unique combination of microvascular and haemodynamic effects.
Consistent with guideline recommendations, in the absence of systemic hypotension, nitrates appear to be a safe and effective. Initial data suggest that when high-dose nitrates are used, they are associated with improved symptoms and reduced mortality in AHF patients.
Future research is needed to support future clinical adoption. National Center for Biotechnology Information , U. Journal List Card Fail Rev v. Card Fail Rev. Mohammad S Alzahri 1. Anita Rohra 1. W Frank Peacock 1. Author information Article notes Copyright and License information Disclaimer. Corresponding author. MSA and AR have no relevant disclosures. E: moc. Received Jan 4; Accepted Apr 7. This article has been cited by other articles in PMC.
Abstract The purpose of this article is to review the clinical efficacy and safety of nitrates in acute heart failure AHF by examining various trials on nitrates in AHF. Keywords: Nitrates, nitroglycerine, nitrite, isosorbide dinitrate, nesiritide, nitric oxide, acute heart failure, congestive heart failure, inotropes, pulmonary congestion, pulmonary oedema, vasodilatation.
Open in a separate window. Are High-dose Nitrates Effective? Potential Mechanism for the Beneficial Effects of Nitrates The exact mechanism for clinical improvement with nitrates is not clearly defined; however, a number of investigators have proposed potential mechanisms. Challenges to Current Guidelines Treatment algorithms suggested by recent ESC guidelines recommend the administration of diuretics to all patients with congestion and the addition of vasodilators e.
Side Effects and Tolerance Physicians have a long-term familiarity with nitrates as they have been used in ischaemic heart disease for years, with well-described side effects. Conclusion A case for the early use of high-dose nitrates in AHF can be made based on the current literature. References 1. The Euro Heart Failure Survey Programme: a survey on the quality of care among patients with heart failure in Europe, part 1: patient characteristics and diagnosis.
Eur Heart J. Cochrane Collaboration. Am Heart J. J Am Coll Cardiol. DOI: Effect of enalapril on survival in patients with reduced left ventricular ejection fraction and congestive heart failure. N Engl J Med. Mechanism of vascular smooth muscle relaxation by organic nitrates, nitrites, nitroprusside and nitric oxide: evidence for the involvement of S-nitrosothiols as active intermediates.
J Pharmacol Exp Ther. Acute heart failure syndromes: clinical scenarios and pathophysiologic targets for therapy. Heart Fail Rev. Keep this medication out of reach of children.
Store it at room temperature and away from excess heat and moisture not in the bathroom. Throw away any medication that is outdated or no longer needed. Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. However, you should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program.
It is important to keep all medication out of sight and reach of children as many containers such as weekly pill minders and those for eye drops, creams, patches, and inhalers are not child-resistant and young children can open them easily. To protect young children from poisoning, always lock safety caps and immediately place the medication in a safe location — one that is up and away and out of their sight and reach.
In case of overdose, call the poison control helpline at If the victim has collapsed, had a seizure, has trouble breathing, or can't be awakened, immediately call emergency services at Do not let anyone else use your medication.
Ask your pharmacist any questions you have about refilling your prescription. It is important for you to keep a written list of all of the prescription and nonprescription over-the-counter medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.
Nitroglycerin Transdermal Patch pronounced as nye troe gli' ser in. Why is this medication prescribed? How should this medicine be used? Other uses for this medicine What special precautions should I follow? What special dietary instructions should I follow? What should I do if I forget a dose? What side effects can this medication cause? Since the effects are related to venodilation and relative arterial hypovolemia, efforts to increase central fluid volume have proven effective.
Intravenous administration of normal saline, in addition to the passive elevation of the patient's legs, may provide adequate support, but there are no controlled trials to prove its effectiveness. Epinephrine or other arterial vasoconstricting agents are not recommended as they will not likely improve the patient's condition and may cause more difficulties in the future.
Methemoglobinemia has some rare reports as a consequence of nitrate overdose. Clinician suspicion should be raised in patients with hypoxemia symptoms despite a lack of respiratory symptoms, normal arterial PO2, and adequate cardiac output. Blood from patients with methemoglobinemia has a "chocolate brown" appearance in color, with no change in color upon exposure to air.
Interprofessional team members including clinicians, cardiology specialists, primary care providers, pharmacists, internists, and nursing staff who work with patients taking nitroglycerin should be fully aware of the indications and contraindications of the drug, as well as the potential adverse effects. Overall, nitroglycerin is relatively safe, and monitoring of the levels is not required.
Pharmacists can assist the team by monitoring for drug-drug interactions. It is currently unknown whether nitroglycerin is excreted in breast milk.
Interprofessional collaboration and information sharing will drive better outcomes with fewer adverse events with nitroglycerine therapy. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U.
StatPearls [Internet]. Search term. Nitroglycerin Kyle H. Author Information Authors Kyle H. Affiliations 1 Central Michigan University. Continuing Education Activity Nitroglycerin is a vasodilatory drug used primarily to provide relief from anginal chest pain. Indications Nitroglycerin is a vasodilatory drug used primarily to provide relief from anginal chest pain. Mechanism of Action As with other nitrates used to treat anginal chest pain, nitroglycerin converts to nitric oxide NO in the body.
Administration Nitroglycerin is most commonly administered as a tablet that is absorbed sublingually. Adverse Effects Nitroglycerin has many adverse effects of significance, most resulting from the vasodilatory effects of the medication. Contraindications The contraindications of nitroglycerine therapy include: Allergic reactions to nitroglycerin are extremely rare, but reports do exist.
Nitroglycerin is contraindicated in patients that have reported allergic symptoms to the medication. Known history of increased intracranial pressure, severe anemia, right-sided myocardial infarction, or hypersensitivity to nitroglycerin are contraindications to nitroglycerin therapy.
Concurrent use of nitroglycerin with PDE-5 inhibitors e. PDE-5 inhibitors have proven to accentuate the hypotensive effects of nitrates and precipitate syncopal episodes.
Monitoring Any testing does not currently monitor nitroglycerin levels as its half-life is approximately 2 to 3 minutes, and the drug undergoes rapid metabolism in the liver. Toxicity Overdose toxicity from nitroglycerin is mainly a consequence of increased vasodilatory response. Enhancing Healthcare Team Outcomes Interprofessional team members including clinicians, cardiology specialists, primary care providers, pharmacists, internists, and nursing staff who work with patients taking nitroglycerin should be fully aware of the indications and contraindications of the drug, as well as the potential adverse effects.
Review Questions Access free multiple choice questions on this topic. Comment on this article. References 1. Parratt JR. Nitroglycerin--the first one hundred years: new facts about an old drug.
J Pharm Pharmacol. Nitric oxide activates guanylate cyclase and increases guanosine 3':5'-cyclic monophosphate levels in various tissue preparations.
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