Buccal versus intravenous nitroglyerin in unstable angina pectoris

Abstract

The clinical syndrome of unstable angina includes patients with the first onset of angina, change in a previous stable pattern or the development of chest pain at rest. Administration of intravenous nitroglycerin is established therapy in unstable angina. Buccal nitroglycerin has been introduced as an alternative means of administering nitroglycerin, which provides relief of anginal pain within 2 to 3 min and a sustained effect for 3 to 5 h. Twenty-nine patients admitted to the coronary care unit due to unstable angina were randomized to receive treatment with nitroglycerin i.v. for 24 h or buccal nitroglycerin every 4 h. Therapy was titrated according to haemodynamic effects. The mean dose of buccal nitroglycerin was 4.42 mg versus 0.45 micrograms.kg-1.min-1 in the intravenous group. The efficacy of treatment was similar in the two groups. Buccal nitroglycerin appeared to cause fewer adverse effects, especially less haemodynamic intolerance and headache, although the differences were not significant. Repeated administration of buccal nitroglycerin appears to be a safe and well tolerated alternative to high-dose i.v. nitroglycerin treatment in unstable angina pectoris.

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

“…One small randomized trial compared intravenous NTG with buccal NTG and found no significant difference in the control of ischemia. 308 An overview of small studies of NTG in MI from the prefibrinolytic era suggested a 35% reduction in mortality rates; 309 in contrast, both the Fourth International Study of Infarct Survival (ISIS-4) 310 and Gruppo Italiano per lo Studio della Sopravvivenza nellinfarto Miocardico (GISSI-3) 311 trials formally tested this hypothesis in patients with suspected MI in the reperfusion era and failed to confirm this magnitude of benefit. However, these large trials are confounded by frequent prehospital and hospital use of NTG in the "control" groups.…”

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

“…One small randomized trial compared intravenous NTG with buccal NTG and found no significant difference in the control of ischemia (308). An overview of small studies of NTG in MI from the prefibrinolytic era suggested a 35% reduction in mortality rates (309); in contrast, both the Fourth International Study of Infarct Survival (ISIS-4) (310) and Gruppo Italiano per lo Studio della Sopravvivenza nell'infarto Miocardico (GISSI-3) (311) trials formally tested this hypothesis in patients with suspected MI in the reperfusion era and failed to confirm this magnitude of benefit.…”

2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

“…One small randomized trial compared intravenous NTG with buccal NTG and found no significant difference in the control of ischemia. 314 An overview of small studies of NTG in MI from the prefibrinolytic era suggested a 35% reduction in mortality rates 315 ; in contrast, both the Fourth International Study of Infarct Survival (ISIS-4) 316 and Gruppo Italiano per lo Studio della Sopravvivenza nell'infarto Miocardico (GISSI-3) 317 trials formally tested this hypothesis by guest on http://circ.ahajournals.org/ Downloaded from in patients with suspected MI in the reperfusion era and failed to confirm this magnitude of benefit. However, these large trials are confounded by frequent prehospital and hospital use of NTG in the "control" groups.…”