Circulation, Vol 67, 276-282, Copyright © 1983 by American Heart Association
GD Curfman, JA Heinsimer, EC Lozner and HL Fung
A prospective, randomized study of i.v. nitroglycerin (TNG) in the
management of repetitive spontaneous angina pectoris was undertaken in 40
consecutive patients. The clinical effectiveness of i.v. TNG (group A) was
compared with that of oral isosorbide dinitrate (ISDN) and topical 2%
nitroglycerin ointment (NO) in combination (group B) during a 72-hour
treatment period. The doses of both nitrate regimens were adjusted so that
the mean arterial pressure in the two groups was reduced by 15 +/- 3% of
control values to the same level (77 mm Hg). The i.v. TNG dose of 10-200
micrograms/min yielded arterial plasma TNG levels of 1.2-65.3 ng/ml and
estimated plasma (arterial) clearance of 106 +/- 55 ml/min/kg of body
weight (mean +/- SD). In group B, the doses were 20-60 mg (oral ISDN) and
1/2-2 inches (NO) every 6 hours. Intravenous TNG reduced the number of
spontaneous ischemic episodes from 3.3 +/- 0.8 per 24 hours during the
control period to 1.0 +/- 0.3 per 24 hours during the treatment period (p
less than 0.01), while the ISDN/NO combination reduced the number of
episodes from 3.1 +/- 0.4 to 1.4 +/- 0.3 (p less than 0.01). Overall, the
magnitude of the therapeutic effect of i.v. TNG was statistically
indistinguishable from that of ISDN/NO, although i.v. TNG did have somewhat
greater clinical benefit on day 2 of the 3-day treatment period.
Furthermore, the data suggested more consistent control of ischemic
episodes with i.v. TNG during the first 24 hours of the trial. Although
both regimens markedly reduced the frequency of spontaneous ischemic
episodes, only 36% of patients in group A and 17% in group B experienced no
ischemic episodes during the study period (NS). Forty-three percent of
patients in group A and 61% in group B (NS) required early coronary artery
bypass surgery to control recurrent ischemic episodes refractory to medical
therapy. We conclude that i.v. TNG and ISDN/NO, when administered in doses
adjusted to produce similar effects on systemic arterial pressure, have
nearly equivalent clinical effects in the management of patients with
frequent episodes of spontaneous angina pectoris. Intravenous TNG offers
the advantage of more consistent control of ischemic episodes during the
first 24 hours of treatment. Nevertheless, the recurrence rate of
spontaneous ischemic episodes during medical therapy is high with both
regimens, and early coronary artery bypass surgery may be required for
long-term management.
ARTICLES
Intravenous nitroglycerin in the treatment of spontaneous angina pectoris: a prospective, randomized trial
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