Bolus IV nitroglycerin treatment of ischemic chest pain in the ED

doi:10.1016/0735-6757(94)90140-6

The American Journal of Emergency Medicine

Volume 12, Issue 3, May 1994, Pages 288-291

https://doi.org/10.1016/0735-6757(94)90140-6 Get rights and content

Abstract

A prospective case series was conducted to demonstrate the safety and efficacy of intravenous nitroglycerin (IV NTG) boluses in the treatment of ischemic chest pain (CP) in the emergency department (ED). Patients with CP symptomatic after sublingual nitroglycerin (SL NTG) therapy with a systolic blood pressure (SBP) greater than 95 mm Hg were included. Patients were treated with IV NTG boluses of 0.05 mg to 0.4 mg during a 1- to 2-minute period per a protocol based on the patient's prebolus SBP. This was followed by a maintenance infusion. Additional NTG boluses were repeated every 5 minutes as needed. The end point of treatment was the resolution of chest discomfort, thrombolysis, or a SBP less than 95 mm Hg. There were 16 cases of CP. All 16 patients treated, ie, 5 with acute myocardial infarction and 11 with unstable angina showed significant decrease in chest discomfort after 1 to 2 boluses. Two of five with acute myocardial infarction and 9 of 11 patients with unstable angina had complete relief of chest pain after 1 to 4 boluses. There were no episodes of hypotension (SBP <90 mm Hg) in any of the 16 cases. The judicious use of IV NTG boluses administered during a 1- to 2-minute period, in the ED, appears safe and efficacious in patients with CP unresponsive to SL NTG therapy.

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Cited by (9)

Effects of prehospital nitroglycerin on hemodynamics and chest pain intensity
2000, Prehospital Emergency Care
Objective. To assess the effects of prehospital nitroglycerin (NTG) on vital signs and chest pain intensity. Methods. A retrospective review of advanced life support (ALS) run sheets was performed in a suburban volunteer emergency medical services (EMS) system receiving 8,000 annual ALS calls. All consecutive patients who were administered NTG by EMS were included. Standardized forms were used to collect data on patient demographics, history, and physical exam. Patients assessed their chest pain (CP) before and after NTG on a verbal numeric scale of 0-10 from least to most severe. The presence of syncope, dysrhythmias, or profound hypotension [loss of peripheral pulses, a systolic blood pressure (SBP) of <90 mm Hg after NTG, or a drop of >100 mm Hg in BP] was noted. Results. One thousand six hundred sixty-two patients received NTG over 18 months, their mean age was 66 years, and 48% were female. Indications for NTG included CP (83%), dyspnea (45%), and congestive heart failure (20%). After NTG administration, the CP score decreased from 6.9 to 4.4 (mean difference = 2.6; 95% CI = 2.4 to 2.8). The CP completely resolved in 10% of the patients. Mean decreases in SBPs and diastolic BPs were 11.8 mm Hg (95% CI = 10.7 to 13.0) and 4.0 mm Hg (95% CI = 2.9 to 5.1). The mean pulse rate increased by 2.7 beats/min (95% CI = 0.6 to 4.9). There were 12 patients with adverse events [0.7% (95% CI = 0.4% to 1.3%)], including profound bradycardia and hypotension (1), transient drop in SBP of 100 mm Hg responding to fluids (6), post-NTG SBP <90 mm Hg (4), and syncope (1). There were no deaths in the prehospital setting. Conclusions. Use of prehospital NTG appears safe. While NTG reduces CP, most patients have residual pain. PREHOSPITAL EMERGENCY CARE 2000;4:290-293
High-dose nitrates in the immediate management of unstable angina: Optimal dosage, route of administration, and therapeutic goals
1998, American Journal of Emergency Medicine
Nitrates are commonly used for rapid relief of ischemia in the initial management of unstable angina. However, their optimal dosage, route of administration, and therapeutic goals have not been fully established. This study was conducted to determine the optimal dosage and mode of administration (intravenous bolus versus sublingual spray) of nitrates and the therapeutic goals of their use in the immediate management of unstable angina. In a single-center prospective trial, 72 consecutive patients with unstable angina accompanied by typical ST-segment depression on electrocardiogram were randomly assigned to receive isosorbide dinitrate either as repeated intravenous boluses or as sublingual sprays while being delivered to the hospital by a mobile intensive care unit. Optimal nitrate dosage was tailored to pain relief while monitoring mean blood pressure reduction to an optimal range (5% to 20%) without dosage restriction. The mean nitrate dosage needed for ischemia control during the first hour of treatment was 7.8 ± 3.8 mg. Optimal blood pressure reduction was achieved by significantly more intravenously treated patients than sublingually treated patients (68% v 41%, P = .037). Intravenously treated patients also experienced a more pronounced therapeutic effect, as assessed by reduction in chest pain score (67% v 39%, P = .0004) and decrease in ST-segment depressions (57% v 27%, P = .004). These results show that higher doses of nitrates than previously recommended are required for ischemia control during the initial management of unstable angina. The use of repeated intravenous boluses is safe and more easily controlled and, therefore, more efficacious than sublingual sprays in inducing the maximal anti-ischemic effect while avoiding significant hypotension.
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1995, American Journal of Emergency Medicine
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2016, Antimicrobial Agents and Chemotherapy
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2009, Journal of Medical Case Reports
Prehospital treatment of the acute coronary syndrom in the emergency medical services in Bavaria
2005, Notarzt

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^☆: Presented at the Pennsylvania chapter of the American College of Emergency Physicians Annual Scientific Assembly, April 27, 1992.

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Original contributionBolus IV nitroglycerin treatment of ischemic chest pain in the ED☆

Abstract

Lancet

Am J Cardiol

Chest

Intravenous nitroglycerin therapy to limit myocardial infarct size, expansion, and complications

Circulation

Intermittent and continuous nitroglycerin infusions for control of myocardial ischemia

Circulation

Intravenous isosorbide dinitrate infusion in the management of unstable angina pectoris refractory to conventional medical therapy

Jpn Circ J

Original contribution
Bolus IV nitroglycerin treatment of ischemic chest pain in the ED☆