Skip to main content
SpringerLink
Log in

Use of nitroglycerin for the treatment of acute myocardial infarction

  • Review
  • Published:
Heart and Vessels Aims and scope Submit manuscript

Summary

After a decade of warnings against the use of nitrates in acute myocardial infarction (MI), they are becoming recognized for their potential to salvage left ventricular (LV) myocardium, geometry and function. Low-dose intravenous (IV) nitroglycerin (NTG) infusion for the first 48 h after acute MI, titrated to lower mean blood pressure by 10% to 30%, but not below 80 mmHg, has been shown to be safe, to improve hemodynamics, and to decrease infarct size, infarct expansion, complications, and deaths in a prospective, randomized, single-blind study of 310 patients. In addition, low-dose NTG infusion for the first 48 h, followed by prolonged buccal NTG given during healing after acute MI in an eccentric dose schedule to minimize tolerance, was found to limit further progressive remodeling and preserve LV function. Meta-analysis of nitrate studies in acute MI indicate that they improve survival. Preliminary and ongoing studies suggest that prolonged NTG therapy post MI can produce further benefit.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Gunnar RM, Fisch C (1990) Special Report: ACC/AHA guidelines for the early management of patients with acute myocardial infarction. Circulation 82:664–707

    Google Scholar 

  2. Brunton TL (1867) On the use of nitrite of amyl in angina pectoris. Lancet II:97–98

    Google Scholar 

  3. Prodger SH, Ayman D (1932) Harmful effects of nitroglycerin: With special reference to coronary thrombosis. Am J Med Sci 184:480–491

    Google Scholar 

  4. Friedberg CK (1966) Acute coronary occlusion and myocardial infarction. In Friedberg CK (ed) Diseases of the heart, 3rd edn. Saunders, Philadelphia, pp 913–914

    Google Scholar 

  5. Jugdutt BI (1984) Intravenous nitroglycerin infusion in acute myocardial infarction: Myocardial salvage. Cardiovasc Rev Rep 5:53–67

    Google Scholar 

  6. Flaherty JT (1984) Intravenous nitroglycerin in acute myocardial infarction. Cardiovasc Rev Rep 5:345–355

    Google Scholar 

  7. Jugdutt BI, Warnica JW (1988) Intravenous nitroglycerin therapy to limit myocardial infarct size, expansion, and complications. Effect of timing, dosage, and infarct location. Circulation 78:906–919

    Google Scholar 

  8. Jugdutt BI, Warnica JW (1989) Tolerance with low-dose intravenous nitroglycerin therapy in acute myocardial infarction. Am J Cardiol 64:581–587

    Google Scholar 

  9. Yusuf S, Collins R, MacMahon S, Peto S (1988) Effect of intravenous nitrates on mortality in acute myocardial infarction: An overview of the randomized trials. Lancet I:1088–1092

    Google Scholar 

  10. Jugdutt BI, Sussex BA, Warnica JW, Rossall RE (1983) Persistent reduction in left ventricular asynergy in patients with acute myocardial infarction by intravenous infusion of nitroglycerin. Circulation 68:1264–1273

    Google Scholar 

  11. Hill NS, Antman EM, Green LH et al. (1981) Intravenous nitroglycerin: A review of pharmacology, indications, therapeutic effects, and complications. Chest 79:69–76

    Google Scholar 

  12. Horwitz LD, Gorlin R, Taylor WJ, Kemp HG (1971) Effects of nitroglycerin on regional myocardial blood flow in coronary artery disease. J Clin Invest 50:1578–1584

    Google Scholar 

  13. Ganz W, Marcus HS (1972) Failure of intracoronary nitroglycerin to alleviate pacing-induced angina. Circulation 46:880–889

    Google Scholar 

  14. Feldman RL, Pepine CJ, Curry RC, Conti CR (1979) Coronary artery responses to graded doses of nitroglycerin. Am J Cardiol 43:91–96

    Google Scholar 

  15. Dauwe F, Affaki G, Waters DD, Theroux P, Mizgala HF (1979) Intravenous nitroglycerin in refractory unstable angina (abstract). Am J Cardiol 43:416

    Google Scholar 

  16. Flaherty JT, Reid PR, Kelly DT, Taylor DR, Weisfeldt ML, Pitt B (1975) Intravenous nitroglycerin in acute myocardial infarction. Circulation 51:132–139

    Google Scholar 

  17. Epstein SE, Kent KM, Goldstein RE, Borer JS, Redwood DR (1975) Reduction of ischemic injury by nitroglycerin during acute myocardial infarction. N Engl J Med 292:29–35

    Google Scholar 

  18. Borer JS, Redwood DR, Levitt B, Cagin N, Bianchi C, Vallin H, Epstein SE (1975) Reduction in myocardial ischemia with nitroglycerin or nitroglycerin plus phenylephrine administration during acute myocardial infarction. N Engl J Med 293:1008–1012

    Google Scholar 

  19. Come PC, Flaherty JT, Weisfeldt M, Baird MG, Rouleau JR, Weisfeldt ML, Greene HL, Becker L, Pitt B (1975) Reversal of the beneficial effects of intravenous nitroglycerin in patients with acute myocardial infarction by phenylephrine. N Engl J Med 293:1003–1007

    Google Scholar 

  20. Flaherty JT, Come PC, Baird MG, Rouleau J, Taylor DR, Weisfeldt ML, Greene HL, Becker LC, Pitt B (1976) Effects of intravenous nitroglycerin on left ventricular function and ST segment changes in acute myocardial infarction. Br Heart J 38:612–621

    Google Scholar 

  21. Bussmann WD, Schofer H, Kurita H, Ganz W (1979) Nitroglycerin in acute myocardial infarction: X. Effect of small and large doses of I.V. nitroglycerin on ST-segment deviation: Experimental and clinical results. Clin Cardiol 2:106–112

    Google Scholar 

  22. Bussmann WD, Passek D, Seidel W, Kaltenbach M (1981) Reduction of CK and CK-MB indexes of infarct size by intravenous nitroglycerin. Circulation 63:615–622

    Google Scholar 

  23. Gunnar RM, Lambrew CT, Abrams W et al. (1982) Task force IV: Pharmacologic interventions. Am J Cardiol 50:393–408

    Google Scholar 

  24. Jugdutt BI, Becker LC, Hutchins GM, Bulkley BH, Reid PR, Kallman CH (1981) Effect of intravenous nitroglycerin on collateral blood flow and infarct size in the conscious dog. Circulation 63:17–28

    Google Scholar 

  25. Jugdutt BI (1983) Myocardial salvage by intravenous nitroglycerin in conscious dogs: Loss of beneficial effect with marked nitroglycerin-induced hypotension. Circulation 68:673–684

    Google Scholar 

  26. Jugdutt BI (1991) Intravenous nitroglycerin unloading in acute myocardial infarction. Am J Cardiol 68:52D–63D

    Google Scholar 

  27. Jugdutt BI (1985) Delayed effects of early infarct-limiting therapies on healing after myocardial infarction. Circulation 72:907–914

    Google Scholar 

  28. Jugdutt BI (1988) Effect of nitroglycerin and ibuprofen on left ventricular topography and rupture threshold during healing after myocardial infarction in the dog. Can J Physiol Pharmacol 66:385–395

    Google Scholar 

  29. Michorowski BL, Senaratne MPJ, Jugdutt BI (1987) Myocardial infarct expansion. Cardiovasc Rev Rep 8:42–48

    Google Scholar 

  30. Michorowski BL, Senaratne MPJ, Jugdutt BI (1987) Deterring myocardial infarct expansion. Cardiovasc Rev Rep 8:55–62

    Google Scholar 

  31. Michorowski BL, Tymchak WJ, Jugdutt BI (1987) Improved left ventricular function and topography by prolonged nitroglycerin therapy after acute myocardial infarction (abstract). Circulation 76[Suppl IV]:IV-128

    Google Scholar 

  32. Tymchak WJ, Michorowski BL, Burton JR, Jugdutt BI (1988) Preservation of left ventricular function and topography with combined reperfusion and intravenous nitroglycerin in acute myocardial infarction (abstract). J Am Coll Cardiol 11:90A

    Google Scholar 

  33. Humen DP, McCormick L, Jugdutt BI (1989) Chronic reduction in left ventricular volumes at rest and exercise in patients treated with nitroglycerin following anterior MI (abstract). J Am Coll Cardiol 13:25A

    Google Scholar 

  34. Jugdutt BI, Neiman JC, Michorowski BL, Tymchak WJ, Genge TJ, Fitzpatrick LK (1990) Persistent improvement in left ventricular geometry and function by prolonged nitroglycerin therapy after anterior transmural acute myocardial infarction (abstract). J Am Coll Cardiol 15:214A.

    Google Scholar 

  35. Jugdutt BI, Tymchak W, Humen D, Gulamhusein S, Hales M (1990) Prolonged nitroglycerin versus captopril therapy on remodeling after transmural myocardial infarction (abstract). Circulation 82[Suppl III]:III-442.

    Google Scholar 

  36. Nelson GIC, Silke B, Ahuya RC, Hussain M, Taylor SH (1983). Haemodynamic advantanges of isosorbide dinitrate over frusemide in acute heart-failure following myocardial infarction. Lancet I:730–733

    Google Scholar 

  37. Gammage MD, Murray RG, Littler WA (1986) Isosorbide-5-mononitrate in the treatment of acute left ventricular failure following acute myocardial infarction. Eur J Clin Pharmacol 29:639–643

    Google Scholar 

  38. Rezakovic DE, Goldner V, Batinic Z, Weiss M, Stalec J, Pavicic L (1990) Intravenous isosorbide-5-mononitrate in the treatment of acute myocardial infarction. Am J Cardiol 65:50J–56J

    Google Scholar 

  39. Jugdutt BI (1981) Effect of PGE1, PGE2, and PGI2 on ventricular arrhythmias during myocardial infarction in conscious dogs: Relation to infarct size. Prostaglandins Leukotrienes Med 7:431–455

    Google Scholar 

  40. Williams DO, Amsterdam EA, Mason DT (1975) Hemodynamic effects of nitroglycerin in acute myocardial infarction: Decrease in ventricular preload at the expense of cardiac output. Circulation 51:421–427

    Google Scholar 

  41. Imhof PR, Ott B, Frankhauser P, Chu LC, Hodler J (1980) Difference in nitroglycerin dose-response in the venous and arterial beds. Eur J Clin Pharmacol 18:455–460

    Google Scholar 

  42. Bassenge E, Stewart DJ (1986) Effects of nitrates in various vascular sections and regions. Z Kardiol 75[Suppl III]:1–7

    Google Scholar 

  43. Chiche P, Baligadoo SJ, Derrida JP (1979) A randomized trial of prolonged nitroglycerin infusion in acute myocardial infarction (abstract). Circulation 59, 60[Suppl II]:II-165

    Google Scholar 

  44. Flaherty JT, Becker LC, Bulkley BH, Weiss JL, Gerstenblith G, Kallman CH, Silverman KJ, Wei JY, Pitt B, Weisfeldt ML (1983) A randomized prospective trial of intravenous nitroglycerin in patients with acute myocardial infarction. Circulation 68:576–588

    Google Scholar 

  45. Jaffe AS, Geltman EM, Tiefenbrunn AJ, Ambos HD, Strauss HD, Sobel BE, Roberts R (1983) Reduction of infarct size in patients with inferior infarction with intravenous glyceryl trinitrate. A randomized study. Br Heart J 49:452–460

    Google Scholar 

  46. Lis Y, Bennett D, Lambert G, Robson D (1984) A preliminary double-blind study of IV nitroglycerin in acute myocardial infarction. Intensive Care Med 10:179–184

    Google Scholar 

  47. Fye B (1986) Nitroglycerin: A homeopathic remedy. Circulation 73:21–29

    Google Scholar 

  48. Stone PH, Raabe DS, Jaffe AS, Gustafson N, Muller JE, Turi ZG, Rutherford JD, Poole WK, Passamani E, Willerson JT, Sobel BE, Robertson T, Braunwald E, for the MILIS Group (1988) Prognostic significance of location and type of myocardial infarction: Independent adverse outcome associated with anterior location. J Am Coll Cardiol 11:453–463

    Google Scholar 

  49. Parker JO (1987) Nitrate tolerance. Am J Cardiol 60:44H–48H

    Google Scholar 

  50. Packer M, Lee WH, Kessler PD, Gottlieb SS, Medina N, Yushak M (1987) Prevention and reversal of nitrate tolerance in patients with congestive heart failure. N Engl J Med 317:799–804

    Google Scholar 

  51. Marcus FI (1990) The rapid onset of nitrate tolerance. J Am Coll Cardiol 16:941–942

    Google Scholar 

  52. Sabia PJ, Powers ER, Ragosta M, Sarembock IJ, Burwell LR, Kaul S (1992) An association between collateral blood flow and myocardial viability in patients with myocardial infarction. N Engl J Med 327:1825–1831

    Google Scholar 

  53. Fujita M, Yamanishi K, Hirai T, Miwa K, Ejiri M, Asanoi H, Sasayama S (1990) Significance of collateral circulation in reversible left ventricular asynergy by nitroglycerin in patients with relatively recent myocardial infarction. Am Heart J 120:521–528

    Google Scholar 

  54. Jugdutt BI (1993) Prevention of ventricular remodelling post myocardial infarction: Timing and duration of therapy. Can J Cardiol 9:103–114

    Google Scholar 

  55. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarcto Miocardico (1987) Long-term effects of intravenous thrombolysis in acute myocardial infarction: Final report of the GISSI study. Lancet II:871–874

    Google Scholar 

  56. ISIS-2 Collaborative Group (1988) Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,987 cases of suspected acute myocardial infarction: ISIS-2. Lancet II:349–360

    Google Scholar 

  57. Swedberg K, Held P, Kjekshus J, Rasmussen K, Ryden L, Wedel H, for the CONSENSUS II Study Group (1992) Effects of early administration of enalapril on mortality in patients with acute myocardial infarction. Results of the cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II). N Engl J Med 327:678–684

    Google Scholar 

  58. Yusuf S (1992) The SOLVD investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 327:685–691

    Google Scholar 

  59. Pfeffer MA, Braunwald E, Moyé LA, Basta L, Brown Jr EJ, Cuddy TE, Davis BR, Geltman EM, Goldman S, Flaker GC, Klein M, Lamas GA, Packer M, Rouleau J, Rouleau JL, Rutherford J, Wertheimer JH, Hawkins CM on behalf of the SAVE Investigators (1992) Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 327:669–677

    Google Scholar 

  60. ISIS-4 Collaborative Group (1991) Fourth International Study of Infarct Survival: Protocol for a large simple study of the effects of oral mononitrate, of oral captopril, and of intravenous magnesium. Am J Cardiol 68:87D–100D

    Google Scholar 

  61. GISSI-3 Investigators (1991) GISSI-3 Pilot Study: Safety of lisinopril and nitroglycerin in the first 72 hours after acute myocardial infarction (abstract). Circulation 84 [Suppl II]:II-366

    Google Scholar 

  62. Palmer RMJ, Ferrige AG, Moncada S (1987) Nitric oxide release accounts for the biological activity of endothelium-derived relaxing factor. Nature 327: 524–526

    Google Scholar 

  63. Lam JYT, Chesebro JH, Fuster V (1988) Platelets, vasoconstriction, and nitroglycerin during arterial wall injury. Circulation 78:712–716

    Google Scholar 

  64. Diodati J, Theroux P, Latour JG, Lacoste L, Lam JYT, Waters D (1990) Effects of nitroglycerin at therapeutic doses on platelet aggregation in unstable angina pectoris and acute myocardial infarction. Am J Cardiol 66:683–688

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. 2C2.43 Walter Mackenzie Health Sciences Centre, Division of Cardiology, University of Alberta, T6G 2R7, Edmonton, Alberta, Canada

    Bodh I. Jugdutt

Authors
  1. Bodh I. Jugdutt
    View author publications

    You can also search for this author in PubMed Google Scholar

Additional information

This study was supported in part by a grant from the Canadian Heart Foundation, Ottawa, Ontario and was presented in part as a Special Lecture at the 7th Millisrol Scientific Meeting on April 4, 1992, in Tokyo, Japan.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Jugdutt, B.I. Use of nitroglycerin for the treatment of acute myocardial infarction. Heart Vessels 9, 3–13 (1994). https://doi.org/10.1007/BF01744490

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF01744490

Key words

Search

Navigation