Sublingual Nitroglycerin In Patients Research Articles

Tekrarlayan Şüpheli Senkoplu Hastalarda Çift Doz Dilaltı Nitrogliserin ile Yapılan Eğik Masa Testinin Reprodusibilitesi

Tekrarlayan Şüpheli Senkoplu Hastalarda Çift Doz Dilaltı Nitrogliserin ile Yapılan Eğik Masa Testinin Reprodusibilitesi

Sublingual nitroglycerin in patients with heart failure and preserved ejection fraction: Impact on central and regional carotid and radial input impedance and hemodynamics

Background: The systolic blood pressure lowering effect of sublingual nitroglycerin (NTG) administration is generally thought to primarily arise from its action on wave reflection, although recent invasive data indicate that at least part of the blood pressure reduction can be ascribed to an effect on left ventricular dynamics. Methods: Carotid and radial pressure waveforms and aortic, carotid and radial flow were measured in 19 HFpEF patients using applanation tonometry and pulsed Doppler ultrasound, respectively. Signals were time-aligned and global systemic as well as regional impedance and wave reflection analysis was applied. Results: NTG lowered carotid systolic (130.8±26 at baseline vs. 110.4±18.4mmHg after NTG, P<0.01) and mean (92.5±18.4 vs.85.4±14.3) blood pressure. Global systemic effects included a decrease in systemic vascular resistance (1.00±0.32 vs. 0.88±0.28 mmHg.ml-1.s, P<0.05), characteristic impedance (0.133±0.089 vs. 0.089±0.034 mmHg.ml-1.s, P<0.05) and an increase in total arterial compliance (1.20±0.58 vs. 1.52±0.53 ml.mmHg-1, P<0.01).NTG had a major impact on the amplitude of the forward pressure wave (58±24.3 vs. 40.6±13.3 mmHg, P<0.01), with no significant change in reflection magnitude. Regional analysis demonstrated a large effect of NTG on carotid input impedance, lowering impedance over the entire frequency spectrum, with radial artery input impedance did not demonstrate any significant changes (despite large effects on pressure and flow waveform morphology). Conclusions: Our data in HFpEF confirm the absence of impact of NTG on reflection magnitude, and demonstrate large effects of NTG on the input impedance of the cerebral vascular district, with little effect on the distal forearm circulation.

Cardiovascular effects of tadalafil

To determine the effects of tadalafil on the cardiovascular system, safety assessments were performed on a database of >4,000 subjects who received tadalafil in >60 clinical pharmacology, phase 2, phase 3, and open-label studies. In healthy subjects, tadalafil resulted in small changes in blood pressure, which are not believed to be clinically relevant. Daily administration of tadalafil 20 mg for 26 weeks in healthy male subjects or patients with mild erectile dysfunction resulted in blood pressure changes similar to those observed after placebo administration. In patients with coronary artery disease (CAD), tadalafil administration before nitrate administration resulted in small decreases in blood pressure. The resulting mean maximal change in standing systolic blood pressure (SBP) after coadministration of sublingual nitroglycerin in patients with chronic stable angina was −36 mm Hg for tadalafil 5 mg, −31 mm Hg for tadalafil 10 mg, and −28 mm Hg for placebo. In addition, a larger number of men had a standing SBP <85 mm Hg after coadministration of sublingual nitroglycerin and tadalafil 5 mg (p <0.001 vs placebo) or tadalafil 10 mg (p <0.01 vs placebo) compared with coadministration with placebo. In patients with chronic stable angina taking doses of isosorbide mononitrate on a long-term basis, the mean maximal change in standing SBP was −23 mm Hg for placebo, −23 mm Hg for tadalafil 5 mg, and −26 mm Hg for tadalafil 10 mg. In a study of older subjects (≥55 years of age) with no overt evidence of CAD, the resulting mean maximal change in standing SBP after coadministration of sublingual nitroglycerin was −25 mm Hg for tadalafil 10 mg, −29 mm Hg for sildenafil 50 mg, and −25 mm Hg for placebo. Cardiac mortality rates in tadalafil studies are consistent with the expected rate in this male population. Across all studies, the incidence rate of myocardial infarction was low in tadalafil-treated patients (0.43 per 100 patient-years) compared with patients who received placebo (0.6 per 100 patient-years), and the incidence rate was comparable to that observed in the age-standardized male population (0.60 per 100 patient-years). The incidence rate of presumed thrombotic strokes in tadalafil studies (0.27 per 100 patient-years) is comparable to the expected rate in this patient population. The data presented herein suggest that tadalafil can be safely used by healthy subjects and by patients with cardiovascular diseases. As with sildenafil, the use of tadalafil is contraindicated in patients receiving nitrate therapy because of the potential for significant hypotensive effects.

Reproducibility of head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope

Head-up tilt testing (HUTT) potentiated with sublingual nitroglycerin has gained acceptance as means of diagnosing neurally mediated syncope. To evaluate the reproducibility of HUTT potentiated with sublingual nitroglycerin, 48 patients with unexplained syncope prospectively underwent 2 consecutive tests 1 to 28 days apart. The initial test ended in syncope in 34 patients (71%). In 9 patients (19%) the test was positive during the drug-free phase, whereas 25 patients (52%) had syncope after nitroglycerin administration. Of these 34 patients with an initial positive test result, 27 (79%) had a reproducible outcome on repeat testing. Of 12 patients (25%) with an initial negative test result, 10 (83%) had a reproducible outcome on repeat testing. Of 2 patients (4%) with a first test ending in exaggerated response, both had a negative repeat test response. The overall reproducibility of sublingual nitroglycerin tilt-table testing was 77%. In a group of 23 patients with both positive tests, 19 (83%) had the same response modality (2 vasodepressor, 4 cardioinhibitory, 13 mixed response). In the same group of patients, individual trough heart rates correlated well with each other between tests. Finally, in the 27 patients with both positive tests, intrapatient time of onset of symptoms did not significantly correlate between tests. Thus, in patients with syncope of unknown origin, HUTT potentiated with sublingual nitroglycerin provides an adequate reproducibility when repeated on different days.

Shortened head-up tilt testing potentiated with sublingual nitroglycerin in patients with unexplained syncope

Background Head-up tilt testing is extensively used to determine the vasovagal origin of syncope in patients with otherwise unexplained loss of consciousness, although issues remain regarding the method of the test. The diagnostic value of a shortened head-up tilt test potentiated with sublingual nitroglycerin was assessed in patients with unexplained syncope. Methods Two hundred two patients (mean age 49 ± 19 years) with syncope of unknown origin and 34 subjects in a control group (mean age 45 ± 17 years) were studied. The patients and the subjects in the control group were tilted upright to 60 degrees for 20 minutes. If syncope did not occur, sublingual nitroglycerin (400 μg) was administered, and observation was continued for 25 more minutes. Results During the unmedicated phase syncope occurred in 22 (11%) patients and in one member of the control group. After nitroglycerin was administered, syncope occurred in 119 (59%) patients and in 1 (3%) member of the control group. False-positive response (exaggerated response) was observed in eight (4%) patients and in four (12%) subjects in the control group. The total positivity rate of the test was 70% with a specificity rate of 94%. Conclusions Short-duration head-up tilt test potentiated with sublingual nitroglycerin provides an adequate specificity and positivity rate in patients with unexplained syncope. (Am Heart J 1998;135:564-70.)

Changes of the carotid artery Doppler flow velocity pattern after sublingual nitroglycerin in patients with hypertension.

ObjectiveTo evaluate the applicability of carotid Doppler echography for the assessment of changes of peripheral hemodynamics in the hypertensives.Subjects28 hypertensives (17 males, 11 females), mean age of 64 yrs and 40 normal controls (24 males, 16 females) mean age of 49 yrs.MethodsWe recorded the right common carotid arterial Doppler flow velocity (BFV) pattern and measured the peak velocities of the percussion wave (P) and late rising tidal wave (T), the ratio of the two (P/T), the time interval between the two peaks corrected by heart rate (P-Tc), systolic flow velocity integral (FVI) and carotid artery diameter (CAD) before and after 0.4 mg dose of subligual nitroglycerin (NTG).Results1) In hypertensives, the P wave velocity showed lower and P-Tc interval shorter than those of the normal controls at baseline. 2) After NTG, the P-Tc and P/T increased, but the T and FVI decreased significantly in both groups of subjects. 3) The P/T ratio was less significantly increased after NTG in the hypertensives than in the controls. These results suggest that NTG might have been involved in concomitant reduction and delay of the wave reflection from the peripheral vessels, preferentially in the normal subjects than in hypertensives.ConclusonThe carotid Doppler echography can be useful for the evaluation of the changes of hemodynamics in the peripheral vessel such as carotid artery in hypertensive subjects.

Effects of sublingual nitroglycerin on the gas exchange response to exercise in stable angina pectoris

To quantitate changes in gas exchange variables that occur after administration of sublingual nitroglycerin in patients with stable angina pectoris, a randomized double-blind 2-period crossover study was performed with continuous expired gas exchange chalysis and progressive exercise using individualized ramp treadmill protocols. Significant reductions in minute ventilation and respiratory rate were observed at 5 minutes of exercise during nitroglycerin therapy. Gas exchange variables i.e., minute ventilation, carbon dioxide production and oxygen uptake were significantly increased at the onset of angina after nitroglycerin administration. When techniques for optimizing the assessment of cardiopulmonary function were used, significant improvements in gas exchange variables were demonstrated in stable angina pectoris after administration of sublingual nitroglycerin.

Effects of sublingual nitroglycerin in patients receiving transdermal nitroglycerin for coronary artery disease: Prevention of cross‐tolerance

The systemic hemodynamic and coronary dilative responses to sublingual nitroglycerin were studied in patients receiving transdermal nitroglycerin. A total of 48 patients with coronary artery disease were divided into 4 groups: 12 patients receiving 1 tablet of sublingual nitroglycerin without transdermal nitroglycerin (Group 1), 12 patients receiving 1 tablet of sublingual nitroglycerin with 12-hour-daily intermittent therapy of transdermal nitroglycerin (Group 2), 12 patients receiving 1 tablet of sublingual nitroglycerin with continuous therapy of transdermal nitroglycerin with continuous therapy of transdermal nitroglycerin (Group 3), and 12 patients receiving 2 tablets of sublingual nitroglycerin with continuous therapy of transdermal nitroglycerin (Group 4). Before and during administration of sublingual nitroglycerin, aortic pressure, left ventricular pressure, and coronary artery diameter were examined at diagnostic cardiac catheterization in all patients. During sublingual nitroglycerin, the decreases of aortic systolic pressure and left ventricular end-diastolic pressure were greater in Group 1, 2, and 4 than in Group 3. Dilation of coronary arteries by sublingual nitroglycerin tended to be greater in Group 1, 2, and 4 than in Group 3. Thus, the effects of sublingual nitroglycerin for the relief of ischemia might be more prominent in patients with intermittent therapy of transdermal nitroglycerin than in those with continuous therapy. The increased dose of sublingual nitroglycerin for the relief of ischemia might be more effective in patients with continuous therapy of transdermal nitroglycerin.

Ineffectiveness of Sublingual Nitroglycerin in Patients with Dry Mucous Membranes

Ineffectiveness of Sublingual Nitroglycerin in Patients with Dry Mucous Membranes

Radionuclide analysis of pulmonary blood volume: The response to spontaneous angina pectoris and sublingual nitroglycerin in patients with coronary artery disease

By manually assigning pulmonary regions of interest and deriving pulmonary time-activity (volume) curves, we were able to make count estimates of pulmonary blood volume (PBV) from gated cardiac blood pool scans. Five patients with coronary heart disease developed angina spontaneously while under a gamma camera. This produced an increase in cardiac volumes ( p < 0.05), a reduction in left ventricular ejection fraction ( p < 0.01), along with a marked increase in PBV (0.010 ± 0.002 to 0.015 ± 0.003 untils, p < 0.05). Nitroglycerin was then administered and reduced PBV in association with a return to normal in cardiac systolic function and size. In patients with stable chronic ischemic heart disease, sublingual nitroglycerin also reduced PBV ( p < 0.05), although not as much as when administered during an anginal episode. We conclude that gated imaging of the chest can be utilized to follow changes in PBV serially. These changes can be utilized to evaluate clinically important changes in hemodynamic status and the response to pharmacologic interventions.

Arterial hypoxemia following the administration of sublingual nitroglycerin in patients with ischemic heart disease and pneumonia.

Nitroglycerin (Ng) is a potent and short-acting coronary and systemic vasodilator, widely used in anginal pain treatment. When given to patients with pneumonia or chronic lung disease, Ng was found to cause a further decrease in arterial oxygen tension (PaO2) by increased perfusion of poorly ventilated territories in the lungs. In order to investigate the potential hazard in Ng decreasing the PaO2 in ischemic heart disease patients, who develop acute pneumonia, we administered 0.4 mg Ng sublingually to 11 patients who suffered concomitantly from ischemic heart disease and acute pneumonia. Arterial blood gases were monitored before, 2, 5 and 10 min following Ng administration, as well as a standard 12-lead electrocardiogram that was monitored as the same time. 8 out of the 11 patients showed a decrease in PaO2 which was mild to moderate, during the study period of time, none of them showed an increase, and there was tendency for the lower (less than 60 mm Hg) initial PaO2 to show a lesser decrease in the PaO2 in comparison to the higher (greater than 60 mm Hg) initial PaO2. There was no statistical significant correlation between the decrease in PaO2 and patients' age, sex, coexisting chronic obstructive lung disease and severity of systemic heart failure. Our conclusion is that the hazard in lowering PaO2 by Ng in ischemic heart disease patients who develop acute pneumonia is minimal, but the drug should be used with caution.

Relief of Pulmonary Congestion by Sublingual Nitroglycerin in Patients with Mitral Valve Disease

Relief of Pulmonary Congestion by Sublingual Nitroglycerin in Patients with Mitral Valve Disease

Relief of Pulmonary Congestion by Sublingual Nitroglycerin in Patients with Mitral Valve Disease

Acute pulmonary congestion may occur in patients with valvular heart disease despite vigorous medical therapy (digitalis-diuretic). Further increases in digitalis or diuretic dosage are then ineffective and may lead to problems of toxicity.1 Sublingual nitroglycerin (SNG) has been shown to be beneficial in emergency treatment of pulmonary edema due to myocardial infarction and valvular heart disease.24 In two patients with acute pulmonary congestion due to valvular heart disease (ruptured chorda tendenea and mitral stenosis) undergoing valve replacement, we used SNG to relieve pulmonary edema. In both patients, within 4 to 5 minutes after administration of SNG (0.8 mg), systolic pulmonary arterial pressure (PAP) and pulmonary capillary wedge pressure (PCWP) decreased significantly with concomitant improvement of clinical symptoms.

Reduction of ischemic injury by sublingual nitroglycerin in patients with acute myocardial infarction.

The effect of sublingual nitroglycerin (NTG) on myocardial ischemic injury was evaluated in eleven patients with acute anterior myocardial infarction. Precordial 35-lead ST-segment maps were obtained in each patient immediately before and 3-10 minutes after 0.4 mg sublingual NTG. The following measurements were made from each ST map: N-ST (number of leads showing ST elevation greater than 1mm), sigmaST (total ST elevation in all leads), ST (average ST-segment elevation in those leads with less than 1mm elevation). Following 0.4 mg sublingual NTG evidence of myocardial ischemic injury as assessed by ST-segment mapping decreased in association with reduction of heart rate X systolic blood pressure product (10.80 X 10(3) to 9.49 X 10(3), P less than 0.001). Group mean values diminished significantly for N-ST (18.1 to 14.4, P less than 0.001), sigma ST (37.9 to 30.1 P less than 0.005) and ST (1.7 to 1.4, P less than 0.001). Evaluation performed by the technique of precordial ST-segment mapping suggests that sublingual nitroglycerin in a commonly employed clinical dose is associated with evidence of reduced ischemic cardiac injury in patients with acute myocardial infarction. This effect appears to be related to reduction of myocardial oxygen demand by the nitrate.

Role of sublingual nitroglycerin in patients with acute myocardial infarction.

Fourteen patients with acute myocardial infarction were given 0.3 mg sublingual nitroglycerin within the first 12 hours of their acute myocardial infarction. Five minutes after sublingual nitroglycerin mean arterial pressure fell 9 mmHg (1.2 kPa) and remained significantly reduced for 30 minutes. Pulmonary capillary wedge pressure fell from a mean control value of 17 to 12 mmHg (2.3 to 1.6 kPa) and also remained reduced for 30 minutes. Heart rate was significantly raised and stroke work index reduced at five minutes. Patients with a stroke work index of greater than 55 g m per m-2 b.s.a. responed to nitroglycerin with a fall in both pulmonary capillary wedge pressue and strokework index while in those with a stroke work index of less than 55 g m per m-2 b.s.a. stroke work index did not fall concomitantly with the fall in pulmonary capillary wedge pressure. In one patient, nitroglycerin led to a precipitious fall in arterial pressure andrecurrence of chest pain.