Nitrates in the management of acute coronary syndrome
- Guy S Reeder, MD
Guy S Reeder, MD
- Section Editor — Coronary Disease
- Professor of Medicine
- Mayo Medical School
- Section Editor
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
Sublingual, intravenous, and oral nitrate preparations are used in the management of acute coronary syndromes. Most of the published data come from patients with myocardial infarction (MI), but the conclusions would apply to patients with unstable angina.
The role of nitrates in the management of acute coronary syndrome, which includes ST-elevation and non-ST elevation MI, as well as unstable angina, will be reviewed here. The role of nitrate therapy in patients in the emergency department suspected of having chest pain due to myocardial ischemia and the overall management of the patient with an MI are discussed separately. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Immediate ED interventions' and "Overview of the acute management of ST elevation myocardial infarction" and "Overview of the acute management of non-ST elevation acute coronary syndromes".)
MECHANISMS OF ACTION
Potential mechanisms by which nitrates can relieve ischemic pain include:
●Dilatation of large coronary arteries and arterioles (>100 millimicrons [nanometers] in diameter), which may lead to increased perfusion of ischemic zones.
●Dilatation of the venous system with decreased preload, reduction in ventricular volume, and a fall in pulmonary capillary wedge pressure. This effect is useful in patients with pulmonary congestion.
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