Sublingual Isosorbide Dinitrate Research Articles

Nitrate-Induced Headache Response in Patients with Coronary Artery Disease and Coronary Artery Ectasia: A Retrospective Case-Control Study

Abstract Background: Coronary artery ectasia (CAE), while being considered a variant of atherosclerosis, harbors distinct features that significantly differ from atherosclerosis in terms of pathophysiological mechanisms. On the other hand, headache appears to be the most common side effect of nitrates that have been used traditionally for decades. In this context, we aimed to compare the frequency and temporal characteristics of nitrate-induced headache (NIH) between subjects with sole coronary artery disease (CAD) and subjects with CAD and coexisting CAE. Materials and Methods: Two hundred and forty-four patients who had undergone coronary angiogram (CAG) and received a single dose of sublingual isosorbide dinitrate during the procedure comprised in this retrospective study population. CAG is performed in the indications due to guidelines. All patients who had undergone CAG were held under close supervision, at least, for 6 h following CAG (and administration of sublingual nitrate); duration and emergence time of NIH were recorded for all patients. Of these 244 patients, 225 patients having sole CAD were assigned to Group I, whereas 19 patients having both CAD and CAE were assigned to Group II. Results: NIH was observed in 19 out of 225 patients (8%) with sole CAD and in 9 out of 19 patients (56%) with CAD and CAE (P = 0.003). The mean interval between the administration of sublingual isosorbide dinitrate and NIH onset was significantly lower in Group II in comparison to Group I (44 ± 14 min vs. 87 ± 63 min, respectively, P = 0.018). However, the duration of NIH was comparable between the two groups (Group I: 203 ± 53 min vs. Group II: 173 ± 61 min, P = 0.24); logistic regression analysis revealed an independent association between NIH and CAE (odds ratio: 11.5, 95% confidential interval: 3.9–33.8, P < 0.001). Conclusion: We have demonstrated that sublingual nitrates might induce NIH more frequently in subjects with CAE and CAD in comparison to those with sole CAD. Furthermore, NIH has been demonstrated to be independently associated with CAE.

English

Angioplasty is considered superior to fibrinolytic therapy in acute myocardial infarction (AMI) if the patient receives it within the therapeutic window. It is unclear if such advantages are available for patients who need to travel from a community hospital to a facility where invasive care is available, since primary thrombolysis often re-establishes coronary artery blood flow in patients with ST elevation acute myocardial infarction (STEMI). At the most severe end of the range of acute coronary syndromes is ST - segment elevation myocardial infarction (STEMI), which generally occurs when a fibrin-rich thrombus fully occludes an epicardial coronary artery. The diagnosis of STEMI is based on clinical features and persistent ST-segment elevation as evidenced by 12 - lead electrocardiography. Patients with STEMI should have a quick reperfusion treatment evaluation and a reperfusion strategy should be performed immediately following contact with the system. All patients with AMI who had chest pain within 12 hours were evaluated. The detailed history of chest pain, character, and radiation, had been taken in terms of duration from the beginning of chest pain in minutes. After 10 minutes, patients were given 10 mg of sublingual isosorbide dinitrate and repeated ECG. Patients were excluded if chest pain or ST elevation was resolved after 10 minutes of nitrate administration. In the analysis only those cases in which chest pain and ST shift were not resolved following sublingual nitrates. Serum CKMB estimates have been performed. All patients were treated with 1.5 million IU streptokinase in 100 ml of normal saline for more than 45 minutes. Clinical assessment for 2 hours every half hour was done to evaluate: 1. Chest pain reduction in a subjective scale percentage and to assess changes in the Killip class. 2. Continuous ECG monitoring of reperfusion rhythm occurrences. Patients are assessed at the end of 2 hours of follow-up for: a. Percentage reduction in subjective chest pain a. A 12 lead ECG to identify changes in the ST height c. Repeat CK-MB estimate. Patients with thrombolysis were classified into two classes on the basis of presence or absence of SCR at the end of two hours of initiation. Those with successful reperfusion were grouped into the SCR Group and into the SCR (negative) Group without successful reperfusion. Coronary prognostic index is a set of questionnaires which prognosticate the outcome in AMI. This review describes the role of Coronary Prognostic Index and thrombolysis in patients of STEMI. KEY WORDS ECG, AMI, STEMI, Angioplasty

Naproxen, isosorbide dinitrate and co-administration cannot prevent post-endoscopic retrograde cholangiopancreatography pancreatitis: Randomized controlled trial.

Backgrounds/AimsAcute pancreatitis is the most widespread complication of endoscopic retrograde cholangiopancreatography. Here, we investigated the efficacy of rectal suppository naproxen, sublingual isosorbide dinitrate and their co-administration in the prevention of post-ERCP pancreatitis.MethodsThis double-blind randomized clinical trial carried out from June 2015 to February 2016 at the Gastrointestinal and Liver Diseases Research Center in Rasht, Iran. A total of 585 patients were selected from candidates for diagnostic or therapeutic ERCP by using the simple sampling method. Patients divided into three groups. Group A received 500 mg naproxen, group B took 5 mg isosorbide dinitrate, and group C was co-administrated both agents before ERCP. The primary outcome measure was the development of pancreatitis onset of pain in the upper abdomen and increase of serum amylase activity more than 3 times over the upper normal limit (60-100 IU/L) within first the 24 h post-ERCP.ResultsTotally, 80 patients developed PEP included 29 (4.9%), 24 (4.1%), and 27 (4.6%) patients in groups A, B, and C, respectively (p=0.845). Longer ERCP time (p=0.041), using diazepam (p=0.033), a higher number of pancreatic ducts cannulation (p<0.001), pancreatic duct injection (p=0.013), and using pancreatic stent (p=0.004) were the predisposing factors for PEP.ConclusionsOur findings indicated that prophylactic naproxen suppository or isosorbide dinitrate sublingually or co-administration had no significant difference in the prevention and severity of PEP, however, enhancing the endoscopist’s skills can be effective. Departments and educational hospitals should develop their assessment and quality assurance measures for the training of fellows’ not only technical training but also an understanding of the diagnostic and therapeutic roles of the procedure.

Combination of Diclofenac and Sublingual Nitrates Is Superior to Diclofenac Alone in Preventing Pancreatitis After Endoscopic Retrograde Cholangiopancreatography

Acute pancreatitis is a major adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Rectal administration of nonsteroidal anti-inflammatory drugs (NSAIDs) decreases the incidence of post-ERCP pancreatitis (PEP). Little is known about the combined effects of sublingual nitrate and NSAIDs. We performed a randomized trial to assess whether the combination of NSAIDs and sublingual nitrate is more effective than NSAIDs alone in preventing PEP. In a prospective superiority trial, eligible patients underwent ERCP at 12 endoscopic units in Japan, from March 2015 through May 2018. Patients were randomly assigned to groups given diclofenac suppositories (50 mg) within 15 minutes after the endoscopic procedure alone (diclofenac-alone group, n= 442) or in combination with sublingual isosorbide dinitrate (5 mg) 5 minutes before the endoscopic procedure (combination group, n= 444). The primary endpoint was the occurrence of PEP. PEP developed in 25 patients in the combination group (5.6%), and in 42 patients in the diclofenac-alone group (9.5%) (relative risk 0.59; 95% confidence interval 0.37-0.95; P= .03). Moderate to severe pancreatitis developed in 4 patients (0.9%) in the combination group, and 10 patients (2.3%) in the diclofenac-alone group (relative risk 0.12; 95% confidence interval 0.13-1.26; P= .12). There was no serious adverse event related to the additional administration of sublingual nitrate. In a randomized controlled trial, we found that prophylaxis with rectal diclofenac and sublingual nitrate significantly reduces the overall incidence of PEP compared with diclofenac suppository alone. ClinicalTrials.gov, no: UMIN 000016274.

Immediate effect of sublingual isosorbide dinitrate in patients with coronary slow flow phenomenon (CSFP)

Immediate effect of sublingual isosorbide dinitrate in patients with coronary slow flow phenomenon (CSFP)

Immediate Effect of Sublingual Isosorbide Dinitrate in Patients with Coronary Slow Flow Phenomenon (CSFP)

Immediate Effect of Sublingual Isosorbide Dinitrate in Patients with Coronary Slow Flow Phenomenon (CSFP)

Comparison of short head-up tilt test with conventional protocol after omission of nonmedicated phase in children and young adults.

Background:Syncope is an important and common clinical condition, and the neurally mediated syncope is the most frequent type of syncope. Tilt testing is considered as a first-line diagnostic test.Materials and Methods:We conducted the conventional and modified tilt test on 200 subjects in the age range of 5-20 years. In conventional protocol, the patient was tilted for up to 15 min without medication. If syncope did not develop, the patient received 0.1 mg/kg sublingual isosorbide dinitrate. Then, the patient was continued to be tilted for another 15 min. In modified tilt test, before starting the test, the patient received 0.1 mg/kg isosorbide dinitrate sublingually in supine position. Then, the table was tilted for a maximum of 25 min or until the test became positive.Results:In conventional tilt test group 79.13% and in modified tilt test group 87.06% of subjects showed positive results. In conventional tilt test, the mean of response time was 17.67 ± 4.74 min. The mean of the total time of conventional tilt test was 49.81 ± 5.57 min. In modified tilt test, the mean of response time was 7.24 ± 4.83 min. The mean of the total time of modified tilt test was 35.09 ± 7.58 min. Furthermore, the means of both response and total times between two groups were significantly different (P < 0.001).Conclusions:Our study showed that we can save about 15-20 min in total test time which may increase the cooperation and compliance of young patients and decrease their anxiety with this new protocol.

Comparison of sublingual isosorbide dinitrate and Valsalva maneuver for detection of obstruction in hypertrophic cardiomyopathy.

IntroductionA left ventricular outflow tract (LVOT) obstruction assessment with a provoking test should be a routine part of the evaluation of patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to compare the utility of the Valsalva maneuver (VM) and sublingual spray application of isosorbide dinitrate (ISDN) for detection of an obstruction.Material and methodsWe prospectively evaluated 81 consecutive HCM patients without severe rest LVOT obstruction (defined as peak rest pressure gradient (PG) ≥ 50 mm Hg). We measured PG at rest, during the VM, after sublingual ISDN spray, and during the VM after ISDN. An obstruction was defined as a PG ≥ 30 mm Hg.ResultsAn obstruction was present in 15 patients (19%) at rest (median and interquartile range of PG 16 (7–26) mm Hg), in 38 patients (47%) during the VM (PG 28 (12–49) mm Hg), in 50 (62%) patients after ISDN (PG 50 (12–79) mm Hg), and in 55 patients (68%) during the VM after ISDN (PG 59 (20–87) mm Hg). The difference in occurrence of obstruction among different provoking tests was statistically significant for all comparisons (p < 0.001, except for the comparison of the ISDN test with the VM during ISDN, p = 0.025).ConclusionsThe ISDN test and the VM are useful screening methods for the detection of an HCM obstruction. Although ISDN appears to be more precise than the VM, the best option is a combination of both methods, which maximizes inducement of LVOT obstruction in patients with HCM.

Presentation, Diagnosis, and Management of Achalasia

Presentation, Diagnosis, and Management of Achalasia

Lack of Effect of Nitrates on Exercise Stress Test Results in Patients with Microvascular Angina

To assess the effects of short-acting nitrates on exercise stress test (EST) results and the relation between EST results and coronary blood flow (CBF) response to nitrates in patients with microvascular angina (MVA). We completed 2 symptom/sign limited ESTs on 2 separate days, in a random sequence and in pharmacological washout, in 29 MVA patients and in 24 patients with obstructive coronary artery disease (CAD): one EST was performed without any intervention (control EST, C-EST), and the other after sublingual isosorbide dinitrate, 5 mg (nitrate EST, N-EST). CBF response to nitroglycerin (25 μg) was assessed in the left anterior descending coronary artery by transthoracic Doppler-echocardiography. At C-EST. ST-segment depression ≥1 mm (STD) was induced in 26 (90 %) and 23 (96 %) MVA and CAD patients, respectively (p=0.42), whereas at N-EST, STD was induced in 25 (86 %) and 14 (56 %) MVA and CAD patients, respectively (p=0.01). Time and rate pressure product at 1 mm STD increased during N-EST, compared to C-EST, in CAD patients (475±115 vs. 365±146 s, p<0.001; and 23511±4352 vs. 20583±6234 bpm∙mmHg, respectively, p=0.01), but not in MVA patients (308±160 vs. 284±136 s; p=0.19; and 21290±5438 vs. 20818±4286 bpm∙mmHg, respectively, p=0.35). In MVA patients, a significant correlation was found between heart rate at STD during N-EST and CBF response to nitroglycerin (r=0.40, p=0.04). Short-acting nitrates improve EST results in CAD, but not in MVA patients. In MVA patients a lower nitrate-dependent coronary microvascular dilation may contribute to the lack of effects of nitrates on EST results.

Comparison of a Shortened Isosorbide Dinitrate‐Potentiated Head‐Up Tilt Testing with the Conventional Protocol: Tolerance and Diagnostic Accuracy

The head-up tilt test (HUT) is widely used to investigate unexplained syncope; however, in clinical practice, it is long and sometimes not well tolerated. To compare the sensitivity, specificity, accuracy, and patients' tolerance of a conventional and shortened HUT. Patients with a history of vasovagal syndrome (VVS) were randomized to a conventional HUT (group I) consisting of 20-minute passive tilt followed by 25 minutes after administration of sublingual isosorbide dinitrate (ISDN), or a shortened HUT (group II) where ISDN was given immediately after tilt and observed for 25 minutes. The control group consisted of age- and gender-matched subjects without VVS symptoms. A specific questionnaire to evaluate tolerance was applied. Sixty patients (29 ± 10 years, 82% female) were included. In group I, 22/30 patients had a positive HUT compared to 21/30 in group II (73% vs 70%, P = 0.77). There was also no difference in the accuracy between the two protocols (63% vs 73%, P = 0.24). The time to positivity was shorter in group II (13.2 minutes vs 30 minutes, P < 0.001). Within the control group (n = 60), the frequency of false-positives was 47% and 23% for the conventional and shortened HUT, respectively (P = 0.058). After conventional HUT, 65.2% subjects reported that the test was too long compared to 25% subjects after the shortened HUT (P = 0.002). In this study, the HUT without passive phase was not inferior to the conventional HUT regarding sensitivity, specificity, and accuracy. Furthermore, the shortened ISDN-potentiated protocol allowed faster diagnosis and was better tolerated.

The effect of sublingual isosorbide dinitrate on acute urinary retention due to benign prostatic hyperplasia

Acute urinary retention (AUR) is one of the most important long-term compli-cations of benign prostatic hyperplasia (BPH). Nitric oxide (NO) as a transmitter can relax smooth muscles of the bladder neck and external sphincter. Several studies have reported that sublingual isosorbide dinitrate (ISDN), as a NO donor, can lead to significant decrease in resting pressure of the external sphincter, and its rapid onset of action may be useful in the treatment of AUR. This study was designed to asses the effect of ISDN on AUR in patients with BPH. In this clinical trial, 60 men with BPH-induced AUR were randomly selected via a simple sampling method. Participants were randomly divided into case and control groups. Patients in the case group received 200 mg of sublingual ISDN and participants in the control group received placebo. After 20 min, participants were asked to void spontaneously and the urine was collected in scale containers. Following this, urethral catheterization was done on all the participants and the residual urine was measured. Data were analyzed using SPSS version 15. There was no signi-ficant difference in the mean age of the two groups (P-value = 0.28). The mean voided urine volume in the case group was 201 mL and, in the control group, it was 18 mL (P = 0.004). About 30% in the case group and 3.3% in the control group could void spontaneously after receiving ISDN or placebo (P = 0.006). In the case group, there was a significant correlation between voided urine volume and total urine volume in the bladder (P = 0.03) and in the size of the prostate (P = 0.001). Our study shows that ISDN can be effective in the treatment of BPH-induced AUR with decrease in bladder outlet resistance. ISDN is more effective in younger men and in those with smaller prostates.

Sublingual isosorbide dinitrate for the detection of obstruction in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is predominantly associated with left ventricular outflow tract (LVOT) obstruction. The assessment of the obstruction with a provoking test should be a routine part of HCM evaluation. The aim of the study was to determine the utility of a sublingual spray application of isosorbide dinitrate (ISDN) for detection of an obstruction. We have prospectively analysed 77 consecutive HCM patients, measuring the LVOT gradient at rest, using the sublingual spray application of ISDN (2.5 mg; after 2, 5, and 10 min), and with exercise echocardiography. An obstruction was defined as a gradient ≥ 30 mmHg. An obstruction was present in 15 patients (19%) at rest, in 42 patients (55%) after ISDN, and in 55 patients (71%) after exercise. The ISDN test had a sensitivity of 76% and the specificity of 100% relative to exercise echocardiography, while at-rest measurements had a sensitivity of 27% and a specificity of 100%. The chronological difference in the prevalence of obstructions during the ISDN test was statistically significant (P < 0.05); at ISDN plus 2 min, obstructions were seen in only 29 patients (38%, gradient 28.8 ± 25.0 mmHg), however, at ISDN plus 5 and 10 min, obstructions were found in 42 patients (55%, gradient 44.5 ± 39.6 mmHg). The ISDN test is a reliable screening method for the detection of an HCM obstruction, however, the measurement should be delayed 5-10 min after the application of ISDN. Patients with negative ISDN tests should undergo exercise echocardiography.

Assessment of endothelial function by means of flow-mediated changes using pulse wave velocity.

Endothelial dysfunction is a leading cause of early development of cardiovascular diseases. Endothelial function can be assessed using ultrasound methods to watch the arterial flow-mediated dilation. It is also possible to find changes in pulse wave velocity (PWV) after induced ischemia related to the vessel diameter changes. Pre- and post-induced ischemia carotid-radial PWV was recorded in 226 hypertensive patients (150 women [63.5+/-12.4 years old] and 76 men [63.2+/-11.8 years old] and 55 healthy patients (38 women [63.1+/-12.6 years old] and 17 men [54.8+/-12.8 years old]). The authors considered normal endothelial function a PWV reduction of 5% from baseline. To assess nondependent endothelial dilation the authors performed carotid-radial PWV after sublingual administration of 5 mg of isosorbide dinitrate in a group of patients with abnormal flow-mediated dilation. A significant PWV reduction of 9.8% in normal patients and only 1.2% among hypertensive patients (P<.0005) was found. After sublingual isosorbide dinitrate intake the authors observed a greater fall in PWV (14%) than that observed in healthy people after induced ischemia. Carotid-radial PWV after induced ischemia decreased significantly in normal participants. No significant changes were observed in hypertensive patients. These results may offer a reliable tool to assess endothelial function in medium-size arteries.

Coronary MR Imaging: Effect of Timing and Dose of Isosorbide Dinitrate Administration

To quantify the effect of sublingual isosorbide dinitrate (ISDN) administration on coronary magnetic resonance (MR) imaging. Written informed consent was obtained from all participants, and the HIPAA-compliant protocol was approved by the Institutional Review Board. Coronary MR imaging was performed at 1.5 T before and after administration of ISDN (2.5 or 5 mg) in 25 healthy adult volunteers (mean age, 23 years +/- 4; nine men, 16 women) with three-dimensional targeted (n = 20, randomized into four groups) or whole-heart (n = 5) acquisitions with gradient-recalled echo (GRE) or balanced steady-state free precession (SSFP) sequences. Image quality was assessed by two cardiologists on a four-point scale. Signal-to-noise ratio (SNR), vessel diameter, and vessel sharpness were characterized. A linear mixed-effects model was used for data analysis. A P value of less than .05 was considered to indicate a significant difference. The maximum SNR enhancement with 5 mg of ISDN (GRE: 22.0% +/- 10.7%; SSFP: 20.1% +/- 6.0%) was similar (P > .05) to that with 2.5 mg (GRE: 21.9% +/- 5.4%; SSFP: 19.1% +/- 3.0%). However, the time to maximum SNR enhancement for the 5-mg dose (15.5 minutes +/- 6.0) was earlier (P < .01) than that for 2.5 mg (23.5 minutes +/- 6.7). The increase in vessel diameter with 5 mg of ISDN was greater than that with 2.5 mg (P < .05 for both GRE and SSFP sequences). The coronary images were sharper after ISDN administration (P < .03). Subjective image quality score significantly improved after ISDN administration for GRE images (P < .05 for both doses) but was similar for SSFP images (P = .24 for 2.5 mg; P = .27 for 5 mg). Whole-heart coronary SNR was improved about 10% after ISDN administration (P < .05). Sublingual ISDN improves coronary MR imaging SNR. Practitioners need to consider the dose and temporal effects of ISDN when performing coronary MR imaging.

UP-3.065: Effects of Isosorbide Dinitrate on the Urinary Flow Rate in Patients with Benign Prostatic Hyperplasia

To compare the immediate effects of a systemic nitric oxide (NO) donor with placebo on the uroflowmetric parameters in patients with benign prostatic hyperplasia (BPH).Eighty patients with the mean age of 61.5 years (range, 49 to 74 years) who suffered from BPH were enrolled in the study. We examined peak flow rate, average flow rate, and residual urine in all the patients. Then, patients were randomized to receive either 20 mg sublingual isosorbide dinitrate (ISDN) (n = 40) or placebo (n = 40) 20 minutes prior to the second uroflowmetry, which was performed one day after the first test.The mean peak flow rate increased from 7.6 ± 0.41 mL/s to 10.2 ± 0.54 mL/s (P = .013) in the ISDN group, while it increased +0.40 mL/s in the placebo group (P > .05). Mean residual urine volume decreased significantly from 51 ± 3.1 mL to 29 ± 2.9 mL and from 56 ± 4.1 to 51 ± 2.6 in the ISDN (P = .02) and the placebo groups (P > .05), respectively. At baseline, the mean arterial pressure was 95 ± 2.1 mmHg and under the influence of the NO-donor, it decreased to 83 ± 1.9 mmHg, which was significant (P < .001). No significant changes of micturition parameters were found in the placebo group.Organic nitrates influence micturition parameters in patients with BPH. This new approach could offer a potential pharmacological option to treat obstructive lower urinary tract symptoms.

Comparison of exercise-rest-reinjection Tl-201 imaging and rest sublingual isosorbide dinitrate Tc-99m MIBI imaging for the assessment of myocardial viability

Nitrate administration has been proposed to enhance the detection of myocardial viability when performing myocardial perfusion imaging. In this study, we aimed to compare Tl-201 exercise-rest-reinjection protocol with rest isosorbide dinitrate (ISDN)-Tc99m MIBI study in the same population examined for the myocardial viability. Twenty-six patients with coronary artery disease who had fixed segmental defects on exercise-rest-Tl-201 imaging were studied. All of them underwent Tl-201 reinjection study. Within 1 week of Tl-201 imaging, rest-Tc99m MIBI imaging was performed after sublingual 5 mg ISDN administration (2-day protocol). For each study, tomograms were divided into 20 segments based on three short-axis slices, one vertical long-axis representing the totality of the left ventricle and regional tracer uptake was quantitatively analyzed. Regional tracer uptake was evaluated in 20 myocardial segments for all patients. Viability was defined as presence of tracer uptake >/=50% of peak activity on each study. A total 520 myocardial segments were assessed by semi quantitative analysis. On the baseline rest Tl-201 studies, 211 segments of the 520 segments that were analyzed had <50% of peak activity. Of these segments, 42 (20%) showed reversibility after reinjection Tl-201 imaging and 55 segments (27%) described as viable on the rest ISDN-Tc99m MIBI imaging. There was 89% concordance between the ISDN-Tc99m MIBI study and Tl-201 reinjection study regarding viable myocardial segments. Of the 23 segments with discordant results, 18 were irreversible on Tl-201 reinjection study, but showed >/=50% uptake on ISDN-Tc99m MIBI. Observation of good agreement between Tl-201 reinjection and ISDN-Tc99m MIBI study studies led us to suggest the use of ISDN enhanced imaging in the evaluation of myocardial viability.

Potential use of isosorbide dinitrate As a new drug for tilt table test of young adult subject: A study of haemodynamic effects

Vasovagal syncope is a common health problem in young adult population. Tilt table test (TTT) is the only method to diagnose vasovagal syncope. Since isoprenaline as a standard provocative drug of TTT is hard to be found in Indonesia, we study the haemodynamic effect of isosorbide dinitrate (ISDN) which has similar venous pooling effect with isoprenaline. Seventeen young healthy adult subjects (age of 28.6 ± 4.7 year old, and 14 males) underwent TTT using 400 μg ISDN spray sublingually as a provocative drug. The haemodynamic changes were observed during baseline and provocative phase. None of 17 subjects experienced of syncope. Although, the systolic, diastolic, and mean arterial blood pressure were significantly decreased and the heart rate significantly increased after ISDN administration, but the changes were not sufficient to cause syncopal event. In conclusion sublingual ISDN spray during TTT of young healthy adult subject changes haemodynamic measures but did not cause syncope. These results give a reasonable basic for ISDN usage as provocative drug of TTT. (Med J Indones 2006; 15:24-9) Keywords: Syncope, vasovagal, tilt table test, nitrate

Perioperative Sublingual Isosorbide Dinitrate for the Prevention of Cardiac Complications in Cardiac Patients Undergoing Noncardiac Surgery

One hundred fifty-two consecutive patients with a known or suspected diagnosis of atherosclerotic coronary artery disease were administered 5 mg sublingual isosorbide dinitrate 2 hours and (1/2) hour preoperatively and every 4 hours postoperatively for 3 days, for the prevention of cardiovascular morbidity and mortality, which could result from various noncardiac surgical procedures; 125 patients received general anesthesia. Cardiovascular complications occurred in 3 patients (1.9%). Two patients did not enter the study, owing to side effects of the medication (1.3%). The complications were 1 each (0.6%) of the following: atrial fibrillation, hypotension, and cardiac arrest. Mortality was 0%. These results are exceptionally favorable when compared to the average cardiovascular morbidity rate of 2.8% to 49% in patients assigned to various risk stratifications in the medical literature.

Relationship of serum uric acid to measures of endothelial function and atherosclerosis in healthy adults

Although uric acid (UA) is considered as an antioxidant, the relationship between serum UA levels and cardiovascular diseases is not clear yet. Higher brachial artery resting diameter (BD), impaired brachial artery flow-mediated dilatation (FMD), increased carotid intima-media thickness (IMT), decreased aortic distensibility (AoD), and increased aortic stiffness index (AoSI) and elastic modulus (AoEM) are predictors for development and/or progression of atherosclerosis. In this study, BD, FMD, carotid IMT, AoD, AoSI and AoEM were studied in healthy subjects with UA concentrations in physiological range. One hundred 24 healthy volunteers between 26 and 55 years of age were included in this study. Each subject had a serum UA levels in normal range. Carotid IMT, BD and brachial FMD were measured by means of high-resolution vascular ultrasound. AoD, AoSI, AoEM were examined by transthoracic echocardiography. Endothelium-dependent dilatation (EDD) was assessed by establishing reactive hyperemia and endothelium-independent dilatation (EID) was determined by using sublingual isosorbide dinitrate. Although carotid IMT and EDD were significantly correlated with UA concentrations (r = 0.346, p < 0.0001; r = -0.255, p < 0.05, respectively), EID measurements were not significantly correlated with serum UA concentrations (r = - 0.105, p > 0.05). In addition, AoSI and AoEM were significantly correlated with serum UA levels (r = 0.368, p < 0.0001; r = -0.366, p < 0.0001, respectively), and there was a significant inverse correlation between AoD and serum UA concentrations (r = -0.366, p < 0.0001). Furthermore, in multivariate analysis, we found that serum UA concentrations were correlated with increased carotid IMT, reduced FMD and increased aortic stiffness independent of other cardiovascular risk factor (beta = 256, p = 0.002; beta = -193, p = 0.03; beta = 0.295, p < 0.0001, respectively). In healthy subjects, increased serum UA concentrations, even in physiological range, are a risk factor for increased carotid IMT, reduced FMD and increased aortic stiffness independent of other cardiovascular risk factor, and other factors related to the metabolic syndrome.