II. History
- Albert Nobel stabilized Nitroglycerin for dynamite
- Some postulate that he died of Nitroglycerin toxicity
III. Medications
-
Short Acting Nitroglycerin (Sublingual Nitroglycerin)
- Peak Levels: 1-2 minutes
- Duration: 30 to 60 minutes
-
Long Acting Nitroglycerin (Isosorbide Dinitrate)
- Onset: 5 minutes for sublingual (30 minutes oral)
- Duration: 1 to 4 hours for sublingual (4-6 hours for oral, 8 hours for sustained release)
-
Intravenous Nitroglycerin
- Onset in 2 minutes
- Duration 3 to 5 minutes
-
Transdermal Nitroglycerin
- Peak levels: 30 to 60 minutes
- Duration: 12-14 hours per day (until patch removed)
-
Nitroglycerin Paste (Ointment)
- Onset: 1 hour
- Duration: 2 to 12 hours
IV. Indications
V. Contraindications
- Aortic Stenosis
- Pulmonary Hypertension
-
Hypotension
- Avoid when systolic Blood Pressure <90 to 100 mmHg or more than 30 mmHg below baseline\
- Phosphodiesterase Inhibitor (e.g. Sildenafil, Tadalafil, Vardenafil)
- Guanylate Cyclase Simulator (Riociguat)
- Right sided Myocardial Infarction (seen with inferior Myocardial Infarction)
- Restrictive Cardiomyopathy (or Pericardial Tamponade, constrictive Pericarditis)
VI. Mechanism
- Relaxes vascular Smooth Muscle
- Venous Dilation (more than Nitroprusside)
- Inhibits venous return (Preload)
- Decreases intra-myocardial wall tension
- Decreases intraventricular work
- Reduces left ventricular filling pressure
- Decreases myocardial oxygen demand
- Reduces Myocardial Ischemia
- Cardiac Output
- Increased in Congestive Heart Failure
- Decreased or normal if no Heart Failure
- Inhibits venous return (Preload)
- Arterial Dilation (less than Nitroprusside)
- Relieves Angina
- Dilates large coronary arteries
- Antagonizes vasospasm
- Increases coronary collateral Blood Flow
- Increases perfusion to ischemic Myocardium
- Decreases Systemic Vascular Resistance
-
Esophageal Spasm also responds to nitrates
- Pain relief with Nitroglycerin is not always Angina
VII. Drug Interactions
-
Phosphodiesterase Inhibitors (e.g. Sildenafil, Tadalafil, Vardenafil)
- Profound hypotensive reaction
- Do not use with Nitroglycerin!
- Nitrates may be used >24 hours after Sildenafil or vardenafil or >48 hours after Tadalafil
- Guanylate Cyclase Simulator (Riociguat)
-
Tissue Plasminogen Activator (Alteplase, tPA)
- IV Nitroglycerin may reduce plasma concentrations
-
Heparin
- IV Nitroglycerin may reduce Anticoagulant response
VIII. Adverse Effects
- Headache
- Methemoglobinemia
- Hypoxemia (Ventilation-perfusion mismatch)
-
Hypotension
- Risk Factors
- Prevention
- Administer Intravenous Fluid bolus
- Reduce Nitrate dose
- Consider Atropine if Bradycardia present
- Rebound Tachycardia
- Peripheral Edema
IX. Safety
- Pregnancy Category C
- Unknown safety in Lactation
X. References
- Orman and Mattu in Herbert (2017) EM:Rap 17(7): 6-7
- Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 70-1
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Related Studies
| nitroglycerin (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| NITROGLYCERIN 0.1 MG/HR PATCH | Generic | $0.48 each |
| NITROGLYCERIN 0.2 MG/HR PATCH | Generic | $0.54 each |
| NITROGLYCERIN 0.3 MG TABLET SL | Generic | $0.14 each |
| NITROGLYCERIN 0.4 MG TABLET SL | Generic | $0.13 each |
| NITROGLYCERIN 0.4 MG/HR PATCH | Generic | $0.68 each |
| NITROGLYCERIN 0.6 MG TABLET SL | Generic | $0.21 each |
| NITROGLYCERIN 0.6 MG/HR PATCH | Generic | $0.78 each |
| NITROGLYCERIN 400 MCG SPRAY | Generic | $17.06 per gram |