The mechanism of cardiovascular action of nitroglycerine. An example of integrated response during the unsteady state

Nitrates and nitrites in the treatment of ischemic cardiac disease

The organic nitrite, amyl of nitrite, was initially used as a therapeutic agent in the treatment of angina pectoris, but was replaced over a decade later by the organic nitrate, nitroglycerin (NTG), due to the ease of administration and longer duration of action. The administration of organic nitrate esters, such as NTG, continues to be used in the treatment of angina pectoris and heart failure since the birth of modern pharmacology. Their clinical effectiveness is due to vasodilator activity in large veins and arteries through an as yet unidentified method of delivering nitric oxide (NO), or a NO-like compound. The major drawback is the development of tolerance with NTG, and the duration and route of administration with amyl of nitrite. Although the nitrites are no longer used in the treatment of hypertension or ischemic heart disease, the nitrite anion has recently been discovered to possess novel pharmacologic actions, such as modulating hypoxic vasodilation, and providing cytoprotection in ischemia-reperfusion injury. Although the actions of these 2 similar chemical classes (nitrites and organic nitrates) have often been considered to be alike, we still do not understand their mechanism of action. Finally, the nitrite anion, either from sodium nitrite or an intermediate NTG form, may act as a storage form for NO and provide support for investigating the use of these agents in the treatment of ischemic cardiovascular states. We review what is presently known about the use of nitrates and nitrites including the historical, current, and potential uses of these agents, and their mechanisms of action.

Intravenous vasodilator therapy in congestive heart failure

The prevalence of congestive heart failure (CHF) is increasing in the US and worldwide, partly because patients are living longer. Treatment of CHF is mostly on an outpatient basis, but inpatient care is required for decompensated CHF, acute CHF or poor response to outpatient treatment. Control of symptoms is usually achieved by diuresis. Intravenous (IV) vasodilators are an important adjunct to the inpatient treatment of CHF. They work mainly by reducing the afterload on the myocardium although preload reduction also occurs. After clinical stabilisation, the goal is to switch to a maintenance oral regimen to be continued as outpatient therapy. The range of IV vasodilators available for inpatient treatment of CHF includes nitrates, phosphodiesterase inhibitors, dobutamine, morphine, ACE inhibitors, B-type natriuretic peptides and endothelin receptor antagonists. As each agent may have a different mechanism or site of action, each agent may affect preload, contractility or afterload to a different extent and it may be desirable to choose one over the other in a particular clinical setting. Examples of standard therapy include dobutamine, milrinone and nitroglycerin. Nesiritide, a B-type natriuretic peptide, is a newer vasodilator and US FDA approved for use in acute CHF. However, most studies with this agent have been in small numbers of patients with anecdotal findings. Larger studies are warranted to pinpoint the efficacy and adverse effects of this agent. It is primarily used to reduce the acuity of decompensated CHF on admission to hospital.Endothelin receptor antagonists show promise in the management of acute CHF, but continue to be investigational. Long-term data on their efficacy and safety are limited. None of the endothelin receptor antagonists are FDA approved for use in patients with CHF.

Sublingual nitroglycerin delays arterial wave reflections despite increased aortic "stiffness" in patients with hypertension: a Doppler echocardiography study

Venodilatation with consequent reduction in left ventricular filling and end-diastolic wall stress is an important mechanism for the beneficial effects of nitroglycerin in ischemic heart disease and in left ventricular failure. The effects of sublingual nitroglycerin on arterial pulsatile hemodynamics are less well defined. Doppler echocardiography and the calibrated subclavian artery pulse tracing were used to assess hemodynamics in subjects with sustained arterial hypertension (n = 25) before and 5 to 10 minutes after sublingual deposition of 0.5 mg glyceryl trinitrate. Aortic characteristic impedance was calculated by averaging the modulus of the input impedance (ratio of pressure to flow) at high frequencies and by calculating the ratio of pressure and flow increments during upstroke. The pressure wave was split into forward and backward components, and the reflection coefficient (the ratio of backward to forward pressures) was calculated. Parameters of the arterial bed were estimated by using 2- and 3-element Windkessel models. Nitroglycerin delayed the return of arterial wave reflections by 17% (P =.02) and increased aortic characteristic impedance by 20% (P =. 01), but it did not influence total arterial compliance. Mean arterial pressure decreased 7% (P =.0001), but pulse pressure did not change. Stroke volume and the acceleration time of aortic root flow decreased by 13% (P =.0001) and 8% (P =.01), respectively. Cardiac output decreased 7% (P =.01), despite an increase in heart rate of 10% (P =.0001). Peripheral resistance tended to decrease (4%, P =.06). Thus, in subjects with sustained hypertension, sublingual nitroglycerin dilates peripheral, predominantly muscular arteries with a subsequent delayed return of reflected pressure waves. Reflex activation of the sympathetic nervous system with consequent increased acceleration of left ventricular ejection seems to counteract the effect of reduced mean arterial pressure (distending pressure) with respect to the "stiffness" of the aorta.

Mechanisms of action and efficacy of nitrates in heart failure

Nitrates exert hemodynamic and possibly nonhemodynamic effects that result in reduced cardiac filling pressures, increased cardiac output, reduced pulmonary vascular pressures, and improvement in symptoms and exercise tolerance in patients with heart failure. Combined with hydralazine, chronic oral administration of isosorbide dinitrate has been demonstrated to improve survival when added to digoxin and diuretic therapy. A long-term improvement in left ventricular ejection fraction in these clinical studies has raised the possibility that the nitrates may be acting at least in part by inhibiting left ventricular remodeling. The precise role of nitrates and the optimal dosing regimen in the therapeutic armamentarium for heart failure, particularly in patients already treated with a converting enzyme inhibitor, remains to be established.

Antihypertensive effect of sustained-release isosorbide dinitrate for isolated systolic systemic hypertension in the elderly

A double-blind, randomized trial was performed in 40 patients, mean age (+/- standard deviation) 80 +/- 4 years, with isolated systolic systemic hypertension to evaluate the antihypertensive effect of oral sustained-release isosorbide dinitrate (ISDN), 20 to 40 mg twice daily, vs placebo. After 12 weeks of treatment, supine systolic blood pressure (BP) decreased from 192 +/- 10 to 162 +/- 12 mm Hg with ISDN (p less than 0.001) and from 189 +/- 10 to 175 +/- 15 mm Hg with placebo (p less than 0.001). On the basis of variance analysis, the decrease in systolic BP was significantly lower with ISDN (27 mm Hg) than with placebo (13 mm Hg). Similar results were observed for supine and erect systolic BP measured at 8 AM and 4 PM, 8 and 12 hours after drug intake. No significant differences in diastolic BP, heart rate or side effects occurred. After the ISDN tapering off-period (2 weeks), systolic BP increased significantly but did not change with placebo. The study provided evidence that in elderly patients with systolic hypertension, sustained-release ISDN induced a selective and sustained decrease in systolic BP, antihypertensive effect was observed 8 and 12 hours after drug administration, and no tolerance phenomenon was noted.

Influence of sublingual nitroglycerin on the digital circulation of man

By means of the digital rheoplethysmographic (RPG) method, the effect of sublingually administered nitroglycerin (NTG), 1/200 gr (0.3 mg), on the digital circulation was studied in 17 normal subjects and 5 patients with ischemic heart disease and angina pectoris. NTG produced dilatation of all digital vessels, reflected especially by increases in total digital volume. NTG produced marked changes in the dicrotic notch of the pulse wave, noted also in inflow volume curves but not in outflow volume curves. The dicrotic notch was displaced later on the descending limb of the digital pulse wave and became deeper and more prominent after NTG. It is suggested that NTG produces disproportionate dilatation of the arterial system, having its greatest effect on arteries near the heart, including the coronaries and great vessels branching off the aorta, and on left intraventricular cavity pressure. This greater regional vasodilatation of vessels near the heart could delay closure of the aortic valve, producing a delayed and prominent dicrotic notch of the pulse wave.

Nitrates for congestive heart failure

The use of nitrates in various sublingual, oral, topical and intravenous forms of treatment of patients with congestive heart failure (CHF) is based on their efficacy in dilating capacitance vessels and reducing elevated ventricular diastolic pressure on both the left and right sides of the heart. Their modest arteriolar and arterial dilating effect may also decrease aortic impedance and produce a slight increase in stroke volume despite the reduction in preload. This favorable hemodynamic response requires relatively large doses of the nitrates but these doses are remarkably well tolerated in the majority of patients with CHF. In chronic CHF there has been evidence from small controlled trials of clinical efficacy (increased exercise tolerance and reduction in symptomatology) as well as hemodynamic efficacy. The combination of nitrates with a more potent arteriolar dilator such as hydralazine or minoxidil has produced a more striking acute hemodynamic benefit. Long-term response to such combined therapy is currently the subject of a Veterans Administration cooperative study. The current recommended approach to nitrate therapy in patients with CHF is to use the dosage necessary to normalize ventricular filling pressure. This can be best assessed in the clinic by monitoring jugular venous pressure. This response often requires dosages of isosorbide dinitrate of 160 to 320 mg daily. Transdermal preparations of nitroglycerin may give more constant blood levels but a large dosage is usually required to produce a sustained hemodynamic effect (40 to 80 cm2).(ABSTRACT TRUNCATED AT 250 WORDS)

A profile of intravenous nitroglycerin use in cardiopulmonary bypass surgery

We studied the indications for use, time to onset of effect, approximate effective concentration and therapeutic success of commercially prepared intravenous nitroglycerin (NTG) in 50 patients undergoing cardiopulmonary bypass (CPB) surgery. Nitroglycerin was used to treat systemic or pulmonary hypertension, myocardial ischaemia and ventricular failure. Twenty-one patients had more than one indication for NTG use. Nineteen of 22 patients with pulmonary hypertension, 12 of 13 patients with ischaemic changes, and 13 of 15 patients with ventricular failure improved during intravenous NTG administration. Hypertension during CPB was ameliorated in only six of ten instances. The time to onset of effect ranged from 4.1 +/- 0.8 to 7.8 +/- 2.8 minutes and the mean approximate effective NTG concentration varied from 1.7 +/- 0.3 to 2.9 +/- 0.7 micrograms . kg-1.min-1 (doses only approximate due to our use of an infusion system which absorbs NTG). Complications from intravenous NTG administration were not seen. We conclude that this NTG preparation facilitates treatment of prebypass hypertension, pulmonary hypertension, myocardial ischaemia and ventricular failure but is less effective for the treatment of hypertension during CPB.

Treatment of vasospastic angina pectoris at rest with nitroglycerin ointment: a short-term controlled study in the coronary care unit

The effectiveness of nitroglycerin ointment in vasospastic angina pectoris at rest was evaluated in 10 patients selected for study. The study was performed after a 24 hour control period, and a randomized single-blind crossover experimental design was followed. Two percent nitroglycerin ointment (15 mg) or placebo ointment was administered every 6 hours for a period of 48 hours each; the first treatment period was followed by a second in which each preparation was used for a 24 hour period. All patients were hospitalized in the coronary care unit; an objective evaluation was carried out using a multichannel electrocardiographic recording to assure recognition of the painless ischemic episodes. Coronary angiography showed critical stenosis of one or two vessels in 9 of the 10 patients; spasm was demonstrated in 3. Results of the ergonovine test were positive in nine of nine patients. Nitroglycerin ointment produced a significant reduction in the mean daily number of episodes during the first (12.5 +/- 3.9 versus 0.5 +/- 0.4, p less than 0.02) as well as the second treatment period (10.6 +/- 3.8 versus 0.6 +/- 0.4, p less than 0.02). These results demonstrate that nitroglycerin ointment provides effective, long-lasting protection against angina due to coronary spasm.

Evaluation of the effects of systemic nitroglycerin on perfusion of ischemic myocardium in coronary heart disease assessed intraoperatively by antegrade blood flow through intact saphenous vein bypass grafts

To evaluate systemic nitroglycerin (NTG) effects on reduced perfusion of ischemic myocardium in coronary disease, intravenous NTG actions on coronary circulatory dynamics were directly assessed intraoperatively during aortocoronary bypass surgery in 24 patients. Thus metered antegrade blood flow was measured through 56 separate intack saphenous vein bypass grafts to analyze NTG perfusion response in the obstructed native coronary artery (CA). In 34 bypassed CA with proximal luminal diameter narrowing greater than 50% to 90%, NTG reduced (p less than 0.01) graft flow (GF) 82 to 63 cc/min, thereby indicating that NTG dilated proximal stenoses with resultant increased CA flow. In 11 bypassed CA obstructed greater than 90% to 100% with well developed collaterals distally, NTG decreased (p less than 0.05) GF 64 to 53 cc/min, thus indicating enhanced collateral flow. In contrast, in 11 bypassed CA obstructions greater than 90% to 100% without collaterals, that NTG increased (p less than 0.02) GF 91 to 100 cc/min indicated NTG nonresponsiveness of the severely diseased CA. Thus systemic NTG improves perfusion to ischemic myocardium subserved by diseased coronaries with less than 90% stenosis or by greater than 90% obstructed vessels with substantial collaterals distally.

Afterload reduction and cardiac performance. Physiologic basis of systemic vasodilators as a new approach in treatment of congestive heart failure

Digitalis and diuretics constitute conventional therapy of congestive heart failure, but systemic vasodilators offer an innovative approach in acute and chronic heart failure of decreasing increased left ventricular systolic wall tension (ventricular afterload) by reducing aortic impedance and/or by reducing cardiac venous return. Thus, vasodilators increase cardiac output (CO) by diminishing peripheral vascular resistance (PVR) and/or decrease increased left ventricular end-diastolic pressure (LVEDP) (ventricular preload) by diminishing venous tone. Concomitantly, there is reduction of myocardial oxygen demand, thereby reliably reducing angina pectoris in coronary disease, and potentially limiting infarct size and ischemia provided systemic arterial pressure remains normal. The vasodilators produce disparate modifications of cardiac function depending upon their differing alterations of preload versus impedance: nitrates principally cause venodilation (decrease LVEDP); nitroprusside, phentolamine and prazosin produce balanced arterial and venous dilation (decrease LVEDP and increase CO) provided left ventricular filling pressure is maintained at the upper limit of normal; whereas hydralazine predominantly effects arteriolar dilation (increases CO). With depressed CO plus highly increased LVEDP and increased PVR, nitrates also induce some increase of CO by reducing PVR. Combined nitroprusside and dopamine synergistically enhance CO and decrease LVEDP. Mechanical counterpulsation aids nitroprusside in acute myocardial infarction. The 30-minute venodilator action of sublingual nitroglycerin is extended for 4 to 6 hours by cutaneous nitroglycerin ointment, by sublingual and oral isosorbide dintrate, and by oral pentaerythritol tetranitrate and sustained-release nitroglycerin capsules. Ambulatory oral vasodilator therapy is provided by long-acting nitrates (relieve pulmonary congestion); hydralazine (improves fatigue); prazosin alone, combined nitrate-hydralazine combined prazosin-hydralazine (improve both dyspnea and fatigue).

The role of vasodilator therapy in heart failure

This article has attempted to summarize the current status of the therapeutic use of vasodilator drugs in acute and chronic heart failure. It is apparent from the increasing number of publications in this area that this alternative to more standard forms of therapy is likely to find a permanent and important place in the management of patients with heart disease. It should also be apparent that ideal drugs for the therapy of chronic heart failure are not yet available. Nevertheless, it is probable that such drugs will emerge and become at least as important as the routine use of digitalis in such patients.

Hemodynamic effects of nitroglycerin ointment in congestive heart failure

The hemodynamic effects of nitroglycerin absorbed transcutaneously from an ointment base were determined in 10 patients with chronic congestive heart failure (9 with ischemic heart disease and 1 with cardiomyopathy). The response was characterized by a decrease in pulmonary capillary wedge pressure from an average of 30 to 19 mm Hg, and an increase in cardiac index from 1.7 to 2.2 liter/min per m2, with concomitant decreases in systemic and pulmonary vascular resistance and an increase in venous capacitance. Mean arterial pressure decreased from 85 to 80 mm Hg, and heart rate remained unchanged. The hemodynamic effects persisted for 3 to 6 hours. These results indicate that nitroglycerin ointment is a hemodynamically potent vasodilating agent with potential value in the therapy of congestive heart failure.

The influence of left ventricular stroke volume on aortic root motion: an echocardiographic study

Aortic root motion was studied in 24 normal volunteers at rest and during the Valsalva maneuver, isometric exercise, and amyl nitrite inhalation. In addition root motion was correlated with the stroke volumes determined at cardiac catheterization in 24 patients. The root has distinct systolic movement, the amplitude and duration of which were easily measured both at rest and during the interventions. At rest,the mean (+/-1 SE) systolic amplitude of the anterior aortic wall was 11.2 +/- 0.5 mm and that of the posterior wall 9.5 +/- 0.3 mm. During the strain phase of the Valsalva maneuver anterior wall amplitude fell to 8.2 +/- 0.4 mm and the posterior wall to 7.3 +/- 0.5 mm (P less than 0.001). With release, anterior wall amplitude rebounded to 12.5 +/- 0.8 mm and the posterior wall to 10.8 +/- o.5 mm, values greater than control (P less than 0.01). With isometric exercise there was no change in amplitude compared to rest; however, amyl nitrite caused an increase in the anterior wall to 13.5 +/-0.8 mm and posterior wall to 11.9 +/-0.6 mm (P less than 0.01). In the patient group the amplitude of posterior wall motion correlated weakly with cardiac index (r = 0.63) and stronger with stroke index (r = 0.78). This study quantifies the echocardiographic pattern of normal aortic root motion. The findings indicate that the aortic root motion is an index of stroke volume; they further suggest that root motion is acutely sensitive to variations in stroke volume since its amplitude changed in accord with the documented effects of the employed maneuvers on stroke volume.

Nitroglycerin treatment following experimental coronary occlusion

The effect of sublingual (0.2 mg.) nitroglycerin (TNG) was studied in anesthetized dogs before and after coronary occlusion. Coronary artery occlusion was accomplished by embolization of the circumflex branch of the left coronary artery. TNG was administered before embolization and again at one minute, one, two, and six hours after embolization. TNG treatment did not significantly increase the number of arrhythmias or deaths compared to untreated animals with coronary occlusion. Hemodynamic and blood biochemical parameters were measured 5 to 15 minutes after TNG treatment. At this time of measurement, blood pressures (AO, LV, LA, PA, RV, RA), cardiac output, pulmonary and systemic resistances, and left ventricle work were not significantly different in the TNG-treated group compared to the animals with coronary occlusion but no TNG treatment. In the first five minutes after TNG administration, aortic pressure is reduced. Blood samples withdrawn five minutes after TNG treatment are not significantly different from the untreated animals in PO2, PCO2, pH, glucose, lactate, pyruvate, free fatty acids, LDH, CPK, and SGOT. It is concluded that TNG is not detrimental to animals with acute coronary occlusion and that TNG has a transient, short-duration effect.

Hemodynamic effects of nitroglycerin in acute myocardial infarction

Nitroglycerin (NTG) has recently been suggested to decrease myocardial ischemia and enhance cardiac pump function during acute myocardial infarction (AMI). To evaluate the sublingual agnet in this condition, the hemodynamic effects of 0.4 mg NTG administered to 16 supine patients during the first 72 hours of AMI were determined serially 5, 10 to 15, and 20 to 30 minutes post-NTG. Data were evaluated for the entire group, as well as for six patients with normal pulmonary artery wedge pressure (PAW) (less than or equal to 12 mm Hg; mean 7) who formed group I and for ten patients with elevated PAW (greater than 12 MM Hg; mean 19) who comprised group II. In the 16 patients, NTG resulted in significant decreases in PAW (14 TO 7 MM Hg; P less than .01), mean systemic arterial pressure (MAP) (95 TO 82 MM Hg; P less than .01), cardiac index (CI) (1.79 TO 1.46 L/min/m-2; P less than .02), stroke index (SI) (24 TO 18 CC/M-2; P less than .01) and stroke work index (SWI) (27 TO 20 GM TIMES M/M-2; P less than .01). These alterations were significant in both subgroups, with the decline in PAW greater (P less than .05), while there was no change in group II. There was no significant change in total peripheral vascular resistance (TPVR) for the entire group or in the two subgroups. This study demonstrates that, regardless of initial left ventricular filling pressure, sublingual NTG given in the acute phase of AMI results in rapid fall in PAW, concomitant with decreases in systemic blood pressure, cardiac output and SWI, without changes in TPVR and with little or no effect on heart rate. Since TPVR was unaltered, the decline in MAP was due to fall in cardiac output. Thus, the principal action of sublingual NTG in AMI appears to be systemic venodilation with consequent reduction of ventricular preload. This effect is translated into decline ofpump output even in patients with high initial filling pressures. Although NTG may rapidly relieve pulmonary congestion and lower myocardial oxygen consumption, use of the agent sublingually is limited in AMI because these salutary effects are accomppanied by potentially deleterious fall in cardiac output and systemic blood pressure.

The dicrotic arterial pulse

The study consisted of observations on nine male patients with palpable dicrotic as evidenced by cardiomegaly and the presence of prominent atrial and ventricular diastolic gallop sounds. Most of these patients were diagnosed as having primary myocardial disease.

The indirect carotid pulse was characterized by a single systolic wave, a low dicrotic notch, and a large dicrotic wave. The direct brachial arterial pressure pulse had a similar configuration with a shortened ejection time index. The hemodynamic data on these patients was characterized by low cardiac output, low stroke volume, elevated pulmonary arterial wedge pressures, and high total systemic resistance. From these observations we conclude that the presence of a marked dicrotic pulse in afebrile patients at rest may indicate severe functional impairment of the myocardium.

Intra-hepatic vascular response to sodium nitrite

1. In the perfused liver of the dog, sodium nitrite produced vasoconstriction in the hepatic arterial bed and, particularly, in the portal venous vascular bed.2. These effects on the hepatic vasculature may account in part for the reduction of venous return and diminution in cardiac output recorded by other workers, and may therefore be a factor in the clinical efficacy of the nitrites in angina pectoris.